REGULATIONS

Vol. 35 Iss. 6 - November 12, 2018

REGISTRAR'S NOTICE: The
following regulatory action is exempt from Article 2 of the Administrative
Process Act in accordance with § 2.2-4006 A 4 c of the Code of Virginia,
which excludes regulations that are necessary to meet the requirements of
federal law or regulations, provided such regulations do not differ materially
from those required by federal law or regulation. The Department of General
Services will receive, consider, and respond to petitions by any interested
person at any time with respect to reconsideration or revision.

Title of Regulation: 1VAC30-41. Regulation for the
Certification of Laboratories Analyzing Drinking Water (amending 1VAC30-41-55).

The amendments update the Code of Federal Regulations
requirements for sampling, analytical methodology, and laboratory certification
of drinking water laboratories, which are incorporated by reference, to July 1,
2018.

C. The exceptions to the requirements for laboratory
certification in 40 CFR 141.28, 40 CFR 141.74(a), 40 CFR
141.89(a)(1), 40 CFR 141.131(b)(3), and 40 CFR 141.131(c)(3) are
incorporated by reference into this chapter.

VA.R. Doc. No. R19-5665; Filed October 19, 2018, 11:49 a.m.

TITLE 4. CONSERVATION AND NATURAL RESOURCES

MARINE RESOURCES COMMISSION

Final Regulation

REGISTRAR'S NOTICE: The
Marine Resources Commission is claiming an exemption from the Administrative
Process Act in accordance with § 2.2-4006 A 11 of the Code of Virginia;
however, the commission is required to publish the full text of final
regulations.

The amendments increase the trip limit to 28,500 pounds for
the commercial Winter II period fishery of October 1 through December 31 and
make administrative changes.

4VAC20-910-30. Minimum size limits.

A. The minimum size limit of scup harvested by
commercial fishing gear shall be nine inches in total length.

B. The minimum size limit of scup harvested by
recreational fishing gear including hook and line, rod and reel, spear, and gig
shall be eight inches in total length.

C. It shall be unlawful for any person to catch and retain
possession of any scup of a total length lesssmaller than the
designated minimum sizessize limit, as described, respectively,
in subsections A and B of this section.

D. It shall be unlawful for any person to sell, trade,
barter, or offer to sell, trade, or barter any scup less than nine inches in
total length.

4VAC20-910-40. Gear restrictions.

It shall be unlawful for any person to place, set, or fish
any fish pot in Virginia tidal waters for the purposes of harvesting scup or to
land in Virginia scup harvested by fish pots whichthat are not
constructed as follows:

A. During the Winter I period January 1 through April
30 of each year, it shall be unlawful for any person to do any of the
following:

1. Possess aboard any vessel in Virginia more than 50,000
pounds of scup.;

2. Land in Virginia more than a total of 50,000 pounds of scup
during each consecutive seven-day landing period, with the first seven-day
period beginning on January 1.; or

B.3. When it is projected and announced that
80% of the coastwide quota for thisthe Winter I period has been
attained, it shall be unlawful for any person to possess aboard any
vessel or to land in Virginia more than a total of 1,000 pounds of scup.

C.B. During the Winter II period
October 1 through December 31 of each year, it shall be unlawful for any person
to possess aboard any vessel or to land in Virginia more than 18,00028,500
pounds of scup.

D.C. During the Summer period May 1
through September 30 of each year, the commercial harvest and landing of scup
in Virginia shall be limited to 14,296 pounds, and it shall be unlawful for any
person to possess aboard any vessel in Virginia more than 5,000 pounds of scup.

E.D. For each of the time periods set forth in
this section, the Marine Resources Commission will give timely notice to the
industry of calculated poundage possession limits and quotas and any
adjustments thereto. It shall be unlawful for any person to possess or to land
any scup for commercial purposes after any winter period coastwide quota or
summer period Virginia quota has been attained and announced as such.

F.E. It shall be unlawful for any buyer of
seafood to receive any scup after any commercial harvest or landing quota has
been attained and announced as such.

G.F. It shall be unlawful for any person
fishing with hook and line, rod and reel, spear, gig, or other recreational
gear to possess more than 30 scup. When fishing is from a boat or vessel where
the entire catch is held in a common hold or container, the possession limit
shall be for the boat or vessel and shall be equal to the number of persons on
board legally eligible to fish multiplied by 30. The captain or operator of the
boat or vessel shall be responsible for any boat or vessel possession limit.
Any scup taken after the possession limit has been reached shall be returned to
the water immediately.

VA.R. Doc. No. R19-5736; Filed October 31, 2018, 10:15 a.m.

TITLE 4. CONSERVATION AND NATURAL RESOURCES

MARINE RESOURCES COMMISSION

Final Regulation

REGISTRAR'S NOTICE: The
Marine Resources Commission is claiming an exemption from the Administrative
Process Act in accordance with § 2.2-4006 A 11 of the Code of Virginia;
however, the commission is required to publish the full text of final
regulations.

The amendments (i) create definitions of "immediate
family member" and "crew member list"; (ii) clarify eligibility
for a license, license transfers, and crew member list requirements; and (iii)
require a verified crew member list be on board the vessel during commercial
hook-and-line fishing activities.

4VAC20-995-15. DefinitionDefinitions.

The following wordterms when used in this
chapter shall have the following meaningmeanings unless the
context indicates otherwise:

"Crew member list" means those individuals
registered to participate in commercial hook-and-line fishing activities with
one or more individuals who possess a valid commercial hook-and-line license.

A. The sale of commercial hook-and-line licenses shall be
limited to registered commercial fishermen meeting either of the following two
requirements, except as provided by subsection B of this section:

1. The fisherman shall have held a 1996possess a valid
Commercial Fisherman Registration License and eligibility for the
commercial hook-and-line license or a 1997 commercial hook-and-line license
that was purchased prior to August 26, 1997, provided the fisherman has
reportedby reporting sales of at least 1,000 pounds of seafood
during the course of the previous two calendar years as documented by
the commission's mandatory harvest reporting program.

2. The fisherman shall holdpossess a valid and
current striped bass permit issued by the Marine Resources Commission in
accordance with 4VAC20-252.

B. The fisherman otherwise qualified under subdivision A 1 of
this section shall have beenbe granted an exemption from the
requirement to report sales of at least 1,000 pounds of seafood during the
course of the previous two calendar years as documented by the
commission's mandatory harvest reporting system.when the following
conditions are met:

1. Exemptions shall be solely based only on a
documented medical hardshipscondition or active military leaveservice that prevented the fisherman from fully satisfying the
requirements described in subdivision A 1 of this section.; and

2. Exemptions mayshall only be granted by the
commissioner or histhe commissioner's designee.

C. The maximum number of general hook-and-line licenses is
established as 200.

D. A random drawing for available commercial hook-and-line
licenses shall be held annually should the number of licensees at the start
of anyby the fifth day of January in the current calendar year be
less than 200. Commercial Fisherman Registration Licensees who have reported
sales of at least 1,000 pounds of seafood harvest during the course of the
previous two calendar years by the 5thfifth day of
January of the current calendar year, as documented by the commission's
mandatory harvest reporting program, but who do not currently possess a commercial
hook-and-line license, shall be eligible for the random drawing.

E. Persons who are eligible to purchase a commercial
hook-and-line license by meeting the provisions of subdivision A 2 of this
section may take only striped bass by commercial hook and line.

F. Any person licensed for commercial hook and line under the
provisions of subdivision A 1 of this section may transfer such license to any
registered commercial fisherman, provided:

1. The transferee has a Commercial Fisherman Registration
License.

2. TheBoth the transferee hasand
transferor have reported sales of at least 1,000 pounds of seafood harvest
during the course of the previous two calendar years by the 5thfifth
day of January, as documented by the commission's mandatory harvest
reporting program.

3. All transfers shall be documented on a form provided by the
Marine Resources Commission and approved by the Marine Resources Commissioner
or histhe commissioner's designee. Upon approval, the person
entering the commercial hook-and-line fishery shall purchase a commercial
hook-and-line license in his own name.

4. Transfers of commercial hook-and-line licenses between immediate
family members shall be exempt from the requirements provided in subdivision 2
of this subsection.

5. No commercial hook-and-line license shall be transferred
more than once per calendar year.

4VAC20-995-30. Prohibitions.

A. It shall be unlawful for any person licensed under the
provisions of 4VAC20-995-20 A 1 or A 2 as a commercial hook-and-line
fisherman to do any of the following unless otherwise specified:

1. Fail to be on board the vessel when that vessel is
operating in a commercial hook-and-line fishing capacity.

2. Have more than three crew members, who need not be
registered commercial fishermen, on board the vessel at any given time
provided that:

a. Crew members do not need to be licensed commercial
fishermen but shall be registered on a crew member list with the
commission on an annual basis and in advance of any fishing in any year; except
that one

b. One crew member per vessel needneeds
not be registered on a crew member list;

b.c. The maximum number of crew members
registered to any commercial hook-and-line licensee at any one time
shall be 15; and

c.d. Any crew registration list submitted by
any commercial hook-and-line fisherman may be revised once per calendar
year.; and

e. A legible and approved crew member list must be
maintained on board the vessel during all commercial hook-and-line activities.

3. Fail to display prominently the commercial hook-and-line license
platesdecals, as provided by the commission, on the starboard and
port sides of the vessel.

4. Fish within 300 yards of any bridge, bridge-tunnel, jetty
or pier from 6 p.m. Friday through 6 p.m. Sunday.

5. Fish within 300 yards of any fixed fishing device.

6. Harvest black drum within 300 yards of the Chesapeake
Bay-Bridge-Tunnel at any time.

7. Fish recreationally on any commercial hook and line vessel
during a commercial fishing trip.

8. Use any hydraulic fishing gear or deck-mounted fishing
equipment.

9. Use any fishing rod and reel or hand line equipped with
more than six hooks.

10. Fish commercially with hook and line aboard any vessel
licensed as a charter boat or head boat while carrying customers for
recreational fishing.

B. It shall be unlawful for any
person to use a commercial hook and line within 300 feet of any bridge,
bridge-tunnel, jetty, or pier during Thanksgiving Day andthrough
the following day or. It shall be unlawful for any person to use a
commercial hook and line during any open recreational striped bass season
in the Chesapeake Bay and its tributaries, except during the period midnight
Sunday through 6 a.m. Friday.

NOTICE: Forms used in
administering the regulation have been filed by the agency. The forms are not
being published; however, online users of this issue of the Virginia Register
of Regulations may click on the name of a form with a hyperlink to access it.
The forms are also available from the agency contact or may be viewed at the
Office of the Registrar of Regulations, 900 East Main Street, 11th Floor,
Richmond, Virginia 23219.

REGISTRAR'S NOTICE:
Forms used in administering the regulation have been filed by the agency. The
forms are not being published; however, online users of this issue of the
Virginia Register of Regulations may click on the name of a form with a
hyperlink to access it. The forms are also available from the agency contact or
may be viewed at the Office of the Registrar of Regulations, 900 East Main
Street, 11th Floor, Richmond, Virginia 23219.

REGISTRAR'S NOTICE:
Forms used in administering the regulation have been filed by the agency. The
forms are not being published; however, online users of this issue of the
Virginia Register of Regulations may click on the name of a form with a
hyperlink to access it. The forms are also available from the agency contact or
may be viewed at the Office of the Registrar of Regulations, 900 East Main
Street, 11th Floor, Richmond, Virginia 23219.

Title of Regulation: 9VAC25-740. Water Reclamation
and Reuse Regulation.

The amendments establish Medicaid coverage for behavioral
therapy services for children under the authority of the Early and Periodic
Screening, Diagnosis and Treatment (EPSDT) program. EPSDT is a mandatory
Medicaid-covered service that offers preventive, diagnostic, and treatment
health care services to individuals from birth through the age 21 years. To be
covered for this service, an individual must have a psychiatric diagnosis
relevant to the need for behavioral therapy services, including autism, autism
spectrum disorders, or other similar developmental delays and must meet the
medical necessity criteria. The amendments define the behavioral therapy
service requirements, medical necessity criteria, provider clinical assessment
and intake procedures, service planning and progress measurement requirements,
care coordination, clinical supervision, and other standards to assure quality.
The behavioral therapy service will be reimbursed by the Department of Medical
Assistance Services outside of the Medallion 3 managed care contracts.

The proposed amendments to 12VAC30-120-180 were not adopted
in the final regulation; therefore, managed care organizations are allowed to
provide services. Changes in that section related to documentation will be
addressed in a separate regulatory action.

Summary of Public Comments and Agency's Response: A
summary of comments made by the public and the agency's response may be
obtained from the promulgating agency or viewed at the office of the Registrar
of Regulations.

12VAC30-50-130. Nursing facility services, EPSDT, including
school health services and family planning.

A. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
Service must be ordered or prescribed and directed or performed within the
scope of a license of the practitioner of the healing arts.

B. Early and periodic screening and diagnosis of individuals
younger than 21 years of age, and treatment of conditions found.

1. Payment of medical assistance services shall be made on
behalf of individuals younger than 21 years of age, who are Medicaid eligible,
for medically necessary stays in acute care facilities, and the accompanying
attendant physician care, in excess of 21 days per admission when such services
are rendered for the purpose of diagnosis and treatment of health conditions
identified through a physical examination.

2. Routine physicals and immunizations (except as provided
through EPSDT) are not covered except that well-child examinations in a private
physician's office are covered for foster children of the local social services
departments on specific referral from those departments.

3. Orthoptics services shall only be reimbursed if medically
necessary to correct a visual defect identified by an EPSDT examination or
evaluation. The department shall place appropriate utilization controls upon
this service.

4. Consistent with the Omnibus Budget Reconciliation Act of
1989 § 6403, early and periodic screening, diagnostic, and treatment services
means the following services: screening services, vision services, dental
services, hearing services, and such other necessary health care, diagnostic
services, treatment, and other measures described in Social Security Act §
1905(a) to correct or ameliorate defects and physical and mental illnesses and
conditions discovered by the screening services and [ whichthat ]
are medically necessary, whether or not such services are covered under the
State Plan and notwithstanding the limitations, applicable to recipients ages
21 years and older, provided for by § 1905(a) of the Social Security Act.

5. Community mental health services. These services in order to
be covered (i) shall meet medical necessity criteria based upon diagnoses made
by LMHPs who are practicing within the scope of their licenses and (ii) are
reflected in provider records and on providers' claims for services by
recognized diagnosis codes that support and are consistent with the requested
professional services.

a. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context clearly
indicates otherwise:

"Adolescent or child" means the individual receiving
the services described in this section. For the purpose of the use of these
terms, adolescent means an individual 12 through 20 years of age; a child means
an individual from birth up to 12 years of age.

"Behavioral health service" means the same as
defined in 12VAC30-130-5160.

"Behavioral health services administrator" or
"BHSA" means an entity that manages or directs a behavioral health
benefits program under contract with DMAS.

"Care coordination" means collaboration and sharing
of information among health care providers, who are involved with an
individual's health care, to improve the care.

"Caregiver" means the same as defined in
12VAC30-130-5160.

"Certified prescreener" means an employee of the
local community services board or behavioral health authority, or its designee,
who is skilled in the assessment and treatment of mental illness and has
completed a certification program approved by the Department of Behavioral
Health and Developmental Services.

"Clinical experience" means providing direct
behavioral health services on a full-time basis or equivalent hours of
part-time work to children and adolescents who have diagnoses of mental illness
and includes supervised internships, supervised practicums, and supervised
field experience for the purpose of Medicaid reimbursement of (i) intensive
in-home services, (ii) day treatment for children and adolescents, (iii)
community-based residential services for children and adolescents who are
younger than 21 years of age (Level A), or (iv) therapeutic behavioral services
(Level B). Experience shall not include unsupervised internships, unsupervised
practicums, and unsupervised field experience. The equivalency of part-time
hours to full-time hours for the purpose of this requirement shall be as
established by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.

"DBHDS" means the Department of Behavioral Health
and Developmental Services.

"Direct supervisor" means the person who provides
direct supervision to the peer recovery specialist. The direct supervisor (i) shall
have two consecutive years of documented practical experience rendering peer
support services or family support services, have certification training as a
PRS under a certifying body approved by DBHDS, and have documented completion
of the DBHDS PRS supervisor training; (ii) shall be a qualified mental health
professional (QMHP-A, QMHP-C, or QMHP-E) as defined in 12VAC35-105-20 with at
least two consecutive years of documented experience as a QMHP, and who has
documented completion of the DBHDS PRS supervisor training; or (iii) shall be
an LMHP who has documented completion of the DBHDS PRS supervisor training who
is acting within his scope of practice under state law. An LMHP providing
services before April 1, 2018, shall have until April 1, 2018, to complete the
DBHDS PRS supervisor training.

"DMAS" means the Department of Medical Assistance
Services and its [ contractor or ] contractors.

"EPSDT" means early and periodic screening,
diagnosis, and treatment.

"Family support partners" means the same as defined
in 12VAC30-130-5170.

"Human services field" means the same as the term is
defined by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.

"Individual service plan" or "ISP" means
the same as the term is defined in 12VAC30-50-226.

"Licensed mental health professional" or
"LMHP" means the same as defined in 12VAC35-105-20.

"LMHP-resident" or "LMHP-R" means the same
as "resident" as defined in (i) 18VAC115-20-10 for licensed
professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family
therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment
practitioners. An LMHP-resident shall be in continuous compliance with the
regulatory requirements of the applicable counseling profession for supervised
practice and shall not perform the functions of the LMHP-R or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Counseling. For purposes of Medicaid reimbursement to their supervisors for
services provided by such residents, they shall use the title
"Resident" in connection with the applicable profession after their
signatures to indicate such status.

"LMHP-resident in psychology" or "LMHP-RP"
means the same as an individual in a residency, as that term is defined in
18VAC125-20-10, program for clinical psychologists. An LMHP-resident in
psychology shall be in continuous compliance with the regulatory requirements
for supervised experience as found in 18VAC125-20-65 and shall not perform the
functions of the LMHP-RP or be considered a "resident" until the
supervision for specific clinical duties at a specific site has been
preapproved in writing by the Virginia Board of Psychology. For purposes of
Medicaid reimbursement by supervisors for services provided by such residents,
they shall use the title "Resident in Psychology" after their
signatures to indicate such status.

"LMHP-supervisee in social work,"
"LMHP-supervisee," or "LMHP-S" means the same as
"supervisee" as defined in 18VAC140-20-10 for licensed clinical
social workers. An LMHP-supervisee in social work shall be in continuous
compliance with the regulatory requirements for supervised practice as found in
18VAC140-20-50 and shall not perform the functions of the LMHP-S or be
considered a "supervisee" until the supervision for specific clinical
duties at a specific site is preapproved in writing by the Virginia Board of
Social Work. For purposes of Medicaid reimbursement to their supervisors for
services provided by supervisees, these persons shall use the title
"Supervisee in Social Work" after their signatures to indicate such
status.

"Peer recovery specialist" or "PRS" means
the same as defined in 12VAC30-130-5160.

"Person centered" means the same as defined in
12VAC30-130-5160.

"Progress notes" means individual-specific
documentation that contains the unique differences particular to the
individual's circumstances, treatment, and progress that is also signed and
contemporaneously dated by the provider's professional staff who have prepared
the notes. Individualized and member-specific progress notes are part of the
minimum documentation requirements and shall convey the individual's status, staff
interventions, and, as appropriate, the individual's progress, or lack of
progress, toward goals and objectives in the ISP. The progress notes shall also
include, at a minimum, the name of the service rendered, the date of the
service rendered, the signature and credentials of the person who rendered the
service, the setting in which the service was rendered, and the amount of time
or units/hours required to deliver the service. The content of each progress
note shall corroborate the time/units billed. Progress notes shall be
documented for each service that is billed.

"Psychoeducation" means (i) a specific form of
education aimed at helping individuals who have mental illness and their family
members or caregivers to access clear and concise information about mental
illness and (ii) a way of accessing and learning strategies to deal with mental
illness and its effects in order to design effective treatment plans and
strategies.

"Psychoeducational activities" means systematic
interventions based on supportive and cognitive behavior therapy that
emphasizes an individual's and his family's needs and focuses on increasing the
individual's and family's knowledge about mental disorders, adjusting to mental
illness, communicating and facilitating problem solving and increasing coping
skills.

"Qualified mental health professional-child" or
"QMHP-C" means the same as the term is defined in 12VAC35-105-20.

"Qualified mental health professional-eligible" or
"QMHP-E" means the same as the term is defined in 12VAC35-105-20 and
consistent with the requirements of 12VAC35-105-590.

"Qualified paraprofessional in mental health" or
"QPPMH" means the same as the term is defined in
12VAC35-105-20 and consistent with the requirements of 12VAC35-105-1370.

"Recovery-oriented services" means the same as
defined in 12VAC30-130-5160.

"Recovery, resiliency, and wellness plan" means the
same as defined in 12VAC30-130-5160.

"Resiliency" means the same as defined in
12VAC30-130-5160.

"Self-advocacy" means the same as defined in
12VAC30-130-5160.

"Service-specific provider intake" means the
face-to-face interaction in which the provider obtains information from the
child or adolescent, and parent or other family member [ or members ],
as appropriate, about the child's or adolescent's mental health status. It
includes documented history of the severity, intensity, and duration of mental
health care problems and issues and shall contain all of the following
elements: (i) the presenting issue/reason for referral, (ii) mental health history/hospitalizations,
(iii) previous interventions by providers and timeframes and response to
treatment, (iv) medical profile, (v) developmental history including history of
abuse, if appropriate, (vi) educational/vocational status, (vii) current living
situation and family history and relationships, (viii) legal status, (ix) drug
and alcohol profile, (x) resources and strengths, (xi) mental status exam and
profile, (xii) diagnosis, (xiii) professional summary and clinical formulation,
(xiv) recommended care and treatment goals, and (xv) the dated signature of the
LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP.

"Services provided under arrangement" means the same
as defined in 12VAC30-130-850.

"Strength-based" means the same as defined in
12VAC30-130-5160.

"Supervision" means the same as defined in
12VAC30-130-5160.

b. Intensive in-home services (IIH) to children and
adolescents [ under ageyounger than ] 21 [ years
of age ] shall be time-limited interventions provided in the
individual's residence and when clinically necessary in community settings. All
interventions and the settings of the intervention shall be defined in the
Individual Service Plan. All IIH services shall be designed to specifically
improve family dynamics, provide modeling, and the clinically necessary
interventions that increase functional and therapeutic interpersonal relations
between family members in the home. IIH services are designed to promote
psychoeducational benefits in the home setting of an individual who is at risk
of being moved into an out-of-home placement or who is being transitioned to
home from an out-of-home placement due to a documented medical need of the
individual. These services provide crisis treatment; individual and family
counseling; communication skills (e.g., counseling to assist the individual and
his parents or guardians, as appropriate, to understand and practice
appropriate problem solving, anger management, and interpersonal interaction,
etc.); care coordination with other required services; and 24-hour emergency
response.

(1) [ These services shall be limited annually to 26
weeks. ] Service authorization shall be required for Medicaid
reimbursement prior to the onset of services. Services rendered before the date
of authorization shall not be reimbursed.

[ (2) Service authorization shall be required for
services to continue beyond the initial 26 weeks.

(3)(2) ] Service-specific provider intakes
shall be required at the onset of services and ISPs shall be required during
the entire duration of services. Services based upon incomplete, missing, or
outdated service-specific provider intakes or ISPs shall be denied
reimbursement. Requirements for service-specific provider intakes and ISPs are
set out in this section.

[ (4)(3) ] These services may only be
rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a
QMHP-E.

c. Therapeutic day treatment (TDT) shall be provided two or
more hours per day in order to provide therapeutic interventions. Day treatment
programs [ , limited annually to 780 units, ] provide
evaluation; medication education and management; opportunities to learn and use
daily living skills and to enhance social and interpersonal skills (e.g.,
problem solving, anger management, community responsibility, increased impulse
control, and appropriate peer relations, etc.); and individual, group and
family counseling.

(1) Service authorization shall be required for Medicaid
reimbursement.

(2) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
service-specific provider intakes and ISPs are set out in this section.

(3) These services may be rendered only by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a QMHP-E.

d. Community-based services for children and adolescents
[ underyounger than ] 21 years of age (Level A)
pursuant to 42 CFR 440.031(d).

(1) Such services shall be a combination of therapeutic
services rendered in a residential setting. The residential services will
provide structure for daily activities, psychoeducation, therapeutic
supervision, care coordination, and psychiatric treatment to ensure the
attainment of therapeutic mental health goals as identified in the individual
service plan (plan of care). Individuals qualifying for this service must
demonstrate medical necessity for the service arising from a condition due to
mental, behavioral or emotional illness that results in significant functional
impairments in major life activities in the home, school, at work, or in the
community. The service must reasonably be expected to improve the child's
condition or prevent regression so that the services will no longer be needed.
The application of a national standardized set of medical necessity criteria in
use in the industry, such as McKesson InterQual® Criteria or an
equivalent standard authorized in advance by DMAS, shall be required for this
service.

(2) In addition to the residential services, the child must
receive, at least weekly, individual psychotherapy that is provided by an LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP.

(3) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.

(4) Authorization shall be required for Medicaid
reimbursement. Services that were rendered before the date of service
authorization shall not be reimbursed.

(5) Room and board costs shall not be reimbursed. DMAS shall
reimburse only for services provided in facilities or programs with no more
than 16 beds.

(6) These residential providers must be licensed by the
Department of Social Services, Department of Juvenile Justice, or Department of
Behavioral Health and Developmental Services under the Standards for Licensed
Children's Residential Facilities (22VAC40-151), Regulation Governing Juvenile
Group Homes and Halfway Houses (6VAC35-41), or Regulations for Children's
Residential Facilities (12VAC35-46).

(7) Daily progress notes shall document a minimum of seven
psychoeducational activities per week. Psychoeducational programming must
include [ , but is not limited to, ] development or
maintenance of daily living skills, anger management, social skills, family
living skills, communication skills, stress management, and any care
coordination activities.

(8) The facility/group home must coordinate services with
other providers. Such care coordination shall be documented in the individual's
medical record. The documentation shall include who was contacted, when the
contact occurred, and what information was transmitted.

(9) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
intakes and ISPs are set out in 12VAC30-60-61.

(10) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.

(1) Such services must be therapeutic services rendered in a
residential setting. The residential services will provide structure for daily
activities, psychoeducation, therapeutic supervision, care coordination, and
psychiatric treatment to ensure the attainment of therapeutic mental health
goals as identified in the individual service plan (plan of care). Individuals
qualifying for this service must demonstrate medical necessity for the service
arising from a condition due to mental, behavioral or emotional illness that
results in significant functional impairments in major life activities in the
home, school, at work, or in the community. The service must reasonably be
expected to improve the child's condition or prevent regression so that the
services will no longer be needed. The application of a national standardized
set of medical necessity criteria in use in the industry, such as McKesson
InterQual® Criteria, or an equivalent standard authorized in advance
by DMAS shall be required for this service.

(2) Authorization is required for Medicaid reimbursement.
Services that are rendered before the date of service authorization shall not
be reimbursed.

(3) Room and board costs shall not be reimbursed. Facilities
that only provide independent living services are not reimbursed. DMAS shall
reimburse only for services provided in facilities or programs with no more
than 16 beds.

(4) These residential providers must be licensed by the
Department of Behavioral Health and Developmental Services (DBHDS) under the
Regulations for Children's Residential Facilities (12VAC35-46).

(5) Daily progress notes shall document that a minimum of
seven psychoeducational activities per week occurs. Psychoeducational
programming must include [ , but is not limited to, ]
development or maintenance of daily living skills, anger management, social
skills, family living skills, communication skills, and stress management. This
service may be provided in a program setting or a community-based group home.

(6) The individual must receive, at least weekly, individual
psychotherapy and, at least weekly, group psychotherapy that is provided as
part of the program.

(7) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.

(8) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services that are based upon incomplete, missing, or outdated
service-specific provider intakes or ISPs shall be denied reimbursement.
Requirements for intakes and ISPs are set out in 12VAC30-60-61.

(9) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.

(10) The facility/group home shall coordinate necessary
services with other providers. Documentation of this care coordination shall be
maintained by the facility/group home in the individual's record. The
documentation shall include who was contacted, when the contact occurred, and
what information was transmitted.

f. Mental health family support partners.

(1) Mental health family support partners are peer recovery
support services and are nonclinical, peer-to-peer activities that engage,
educate, and support the caregiver and an individual's self-help efforts to
improve health recovery resiliency and wellness. Mental health family support partners
is a peer support service and is a strength-based, individualized service
provided to the caregiver of a Medicaid-eligible individual younger than 21
years of age with a mental health disorder that is the focus of support. The
services provided to the caregiver and individual must be directed exclusively
toward the benefit of the Medicaid-eligible individual. Services are expected
to improve outcomes for individuals younger than 21 years of age with complex
needs who are involved with multiple systems and increase the individual's and
family's confidence and capacity to manage their own services and supports
while promoting recovery and healthy relationships. These services are rendered
by a PRS who is (i) a parent of a minor or adult child with a similar mental
health disorder or (ii) an adult with personal experience with a family member
with a similar mental health disorder with experience navigating behavioral
health care services. The PRS shall perform the service within the scope of his
knowledge, lived experience, and education.

(2) Under the clinical oversight of the LMHP making the
recommendation for mental health family support partners, the peer recovery
specialist in consultation with his direct supervisor shall develop a recovery,
resiliency, and wellness plan based on the LMHP's recommendation for service,
the individual's and the caregiver's perceived recovery needs, and any clinical
assessments or service specific provider intakes as defined in this section
within 30 calendar days of the initiation of service. Development of the
recovery, resiliency, and wellness plan shall include collaboration with the
individual and the individual's caregiver. Individualized goals and strategies
shall be focused on the individual's identified needs for self-advocacy and
recovery. The recovery, resiliency, and wellness plan shall also include
documentation of how many days per week and how many hours per week are
required to carry out the services in order to meet the goals of the plan. The
recovery, resiliency, and wellness plan shall be completed, signed, and dated
by the LMHP, the PRS, the direct supervisor, the individual, and the
individual's caregiver within 30 calendar days of the initiation of service.
The PRS shall act as an advocate for the individual, encouraging the individual
and the caregiver to take a proactive role in developing and updating goals and
objectives in the individualized recovery planning.

(3) Documentation of required activities shall be required as
set forth in 12VAC30-130-5200 A and C through J.

(4) Limitations and exclusions to service delivery shall be
the same as set forth in 12VAC30-130-5210.

(5) Caregivers of individuals younger than 21 years of age who
qualify to receive mental health family support partners (i) care for an
individual with a mental health disorder who requires recovery assistance and
(ii) meet two or more of the following:

(a) Individual and his caregiver need peer-based
recovery-oriented services for the maintenance of wellness and the acquisition
of skills needed to support the individual.

(b) Individual and his caregiver need assistance to develop
self-advocacy skills to assist the individual in achieving self-management of
the individual's health status.

(c) Individual and his caregiver need assistance and support
to prepare the individual for a successful work or school experience.

(d) Individual and his caregiver need assistance to help the
individual and caregiver assume responsibility for recovery.

(6) Individuals 18 through 20 years of age who meet the
medical necessity criteria in 12VAC30-50-226 B 7 e, who would benefit from
receiving peer supports directly and who choose to receive mental health peer
support services directly instead of through their caregiver, shall be
permitted to receive mental health peer support services by an appropriate PRS.

(7) To qualify for continued mental health family support
partners, the requirements for continued services set forth in 12VAC30-130-5180
D shall be met.

(8) Discharge criteria from mental health family support
partners shall be the same as set forth in 12VAC30-130-5180 E.

(9) Mental health family support partners services shall be
rendered on an individual basis or in a group.

(10) Prior to service initiation, a documented recommendation
for mental health family support partners services shall be made by a licensed
mental health professional (LMHP) who is acting within his scope of practice
under state law. The recommendation shall verify that the individual meets the
medical necessity criteria set forth in subdivision 5 [ a (5) ]
of this subsection. The recommendation shall be valid for no longer than 30
calendar days.

(11) Effective July 1, 2017, a peer recovery specialist shall
have the qualifications, education, experience, and certification required by
DBHDS in order to be eligible to register with the Virginia Board of Counseling
on or after July 1, 2018. Upon the promulgation of regulations by the Board of
Counseling, registration of peer recovery specialists by the Board of
Counseling shall be required. The PRS shall perform mental health family
support partners services under the oversight of the LMHP making the
recommendation for services and providing the clinical oversight of the
recovery, resiliency, and wellness plan.

(12) The PRS shall be employed by or have a contractual
relationship with the enrolled provider licensed for one of the following:

(a) Acute care general and emergency department hospital
services licensed by the Department of Health.

(g) A community mental health and rehabilitative services
provider licensed by the Department of Behavioral Health and Developmental
Services as a provider of one of the following community mental health and
rehabilitative services as defined in this section, 12VAC30-50-226,
12VAC30-50-420, or 12VAC30-50-430 for which the individual younger than 21
years meets medical necessity criteria (i) intensive in home; (ii)
therapeutic day treatment; (iii) day treatment or partial hospitalization;
(iv) crisis intervention; (v) crisis stabilization; (vi) mental health skill
building; or (vii) mental health case management.

(13) Only the licensed and enrolled provider as referenced in
subdivision 5 f (12) of this subsection shall be eligible to bill and receive
reimbursement from DMAS or its contractor for mental health family support
partner services. Payments shall not be permitted to providers that fail to
enter into an enrollment agreement with DMAS or its contractor. Reimbursement
shall be subject to retraction for any billed service that is determined not to
be in compliance with DMAS requirements.

(14) Supervision of the PRS shall be required as set forth in
12VAC30-130-5190 E and 12VAC30-130-5200 G.

6. Inpatient psychiatric services shall be covered for
individuals younger than age 21 for medically necessary stays in inpatient
psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2) for the
purpose of diagnosis and treatment of mental health and behavioral disorders
identified under EPSDT when such services are rendered by (i) a psychiatric
hospital or an inpatient psychiatric program in a hospital accredited by the
Joint Commission on Accreditation of Healthcare Organizations; or (ii) a
psychiatric facility that is accredited by the Joint Commission on Accreditation
of Healthcare Organizations or the Commission on Accreditation of
Rehabilitation Facilities. Inpatient psychiatric hospital admissions at general
acute care hospitals and freestanding psychiatric hospitals shall also be
subject to the requirements of 12VAC30-50-100, 12VAC30-50-105, and
12VAC30-60-25. Inpatient psychiatric admissions to residential treatment
facilities shall also be subject to the requirements of Part XIV
(12VAC30-130-850 et seq.) of Amount, Duration and Scope of Selected Services.

a. The inpatient psychiatric services benefit for individuals
younger than 21 years of age shall include services defined at 42 CFR 440.160
that are provided under the direction of a physician pursuant to a
certification of medical necessity and plan of care developed by an
interdisciplinary team of professionals and shall involve active treatment
designed to achieve the child's discharge from inpatient status at the earliest
possible time. The inpatient psychiatric services benefit shall include
services provided under arrangement furnished by Medicaid enrolled providers
other than the inpatient psychiatric facility, as long as the inpatient
psychiatric facility (i) arranges for and oversees the provision of all
services, (ii) maintains all medical records of care furnished to the
individual, and (iii) ensures that the services are furnished under the
direction of a physician. Services provided under arrangement shall be
documented by a written referral from the inpatient psychiatric facility. For
purposes of pharmacy services, a prescription ordered by an employee or
contractor of the facility who is licensed to prescribe drugs shall be
considered the referral.

b. Eligible services provided under arrangement with the
inpatient psychiatric facility shall vary by provider type as described in this
subsection. For purposes of this section, emergency services means the same as
is set out in 12VAC30-50-310 B.

c. Inpatient psychiatric services are reimbursable only when
the treatment program is fully in compliance with (i) 42 CFR Part 441 Subpart
D, specifically 42 CFR 441.151(a) and (b) and [ 42 CFR ]
441.152 through [ 42 CFR ] 441.156, and (ii) the conditions of
participation in 42 CFR Part 483 Subpart G. Each admission must be
preauthorized and the treatment must meet DMAS requirements for clinical
necessity.

d. Service limits may be exceeded based on medical necessity
for individuals eligible for EPSDT.

7. Hearing aids shall be reimbursed for individuals younger
than 21 years of age according to medical necessity when provided by
practitioners licensed to engage in the practice of fitting or dealing in
hearing aids under the Code of Virginia.

9. Services facilitators shall be required for all consumer-directed
personal care services consistent with the requirements set out in
12VAC30-120-935.

10. Behavioral therapy services shall be covered for
individuals [ under the age of younger than ]
21 years [ of age ].

a. Definitions. The following words and terms when used in
this subsection shall have the following meanings unless the context clearly
indicates otherwise:

"Behavioral therapy" means systematic
interventions provided by licensed practitioners acting within the scope of
practice defined under a Virginia [ Department of ] Health
Professions [ Regulatory Board regulatory board ]
and covered as remedial care under 42 CFR 440.130(d) [ within
the home ] to individuals [ under
younger than ] 21 years of age. Behavioral therapy includes applied
behavioral analysis [ and is primarily provided in the family
home ]. Family [ counseling and ] training
related to the implementation of the behavioral therapy shall be included as
part of the behavioral therapy service. Behavioral therapy services shall be subject
to clinical reviews and determined as medically necessary. Behavioral therapy
may be [ intermittently ] provided in
[ the individual's home and ] community settings
[ when approved settings are as ] deemed by
DMAS or its contractor as medically necessary treatment.

[ "Counseling" means a professional mental
health service that can only be provided by a person holding a license issued
by a health regulatory board at the Department of Health Professions, which
includes conducting assessments, making diagnoses of mental disorders and
conditions, establishing treatment plans, and determining treatment
interventions. ]

"Individual" means the child or adolescent
[ under the age of younger than ] 21
[ years of age ] who is receiving behavioral therapy services.

"Primary care provider" means a licensed medical
practitioner who provides preventive and primary health care and is responsible
for providing routine EPSDT screening and referral and coordination of other
medical services needed by the individual.

b. Behavioral therapy services shall be designed to enhance
communication skills and decrease maladaptive patterns of behavior, which if
left untreated, could lead to more complex problems and the need for a greater
or a more intensive level of care. The service goal shall be to ensure the
individual's family or caregiver is trained to effectively manage the
individual's behavior in the home using modification strategies. [ The
All ] services shall be provided in accordance with the [ individual
service plan ISP ] and clinical assessment summary.

c. Behavioral therapy services shall be covered when
recommended by the individual's primary care provider or other licensed
physician, licensed physician assistant, or licensed nurse practitioner and
determined by DMAS or its contractor to be medically necessary to correct or
ameliorate significant impairments in major life activities that have resulted
from either developmental, behavioral, or mental disabilities. Criteria for
medical necessity are set out in 12VAC30-60-61 H. Service-specific provider
intakes shall be required at the onset of these services in order to receive
authorization for reimbursement. Individual service plans (ISPs) shall be
required throughout the entire duration of services. The services shall be
provided in accordance with the individual service plan and clinical assessment
summary. These services shall be provided in settings that are natural or
normal for a child or adolescent without a disability, such as [ his
the individual's ] home, unless there is justification in the ISP,
which has been authorized for reimbursement, to include service settings that
promote a generalization of behaviors across different settings to maintain the
targeted functioning outside of the treatment setting in the [ patient's
residence individual's home ] and the larger community
within which the individual resides. Covered behavioral therapy services shall
include:

2. School divisions may provide routine well-child screening
services under the State Plan. Diagnostic and treatment services that are
otherwise covered under early and periodic screening, diagnosis and treatment
services [ , ] shall not be covered for school divisions.
School divisions to receive reimbursement for the screenings shall be enrolled
with DMAS as clinic providers.

a. Children enrolled in managed care organizations shall
receive screenings from those organizations. School divisions shall not receive
reimbursement for screenings from DMAS for these children.

b. School-based services are listed in a recipient's
individualized education program (IEP) and covered under one or more of the
service categories described in § 1905(a) of the Social Security Act.
These services are necessary to correct or ameliorate defects of physical or
mental illnesses or conditions.

3. Service providersProviders shall be licensed
under the applicable state practice act or comparable licensing criteria by the
Virginia Department of Education [ , ] and shall meet
applicable qualifications under 42 CFR Part 440. Identification of defects,
illnesses or conditions and services necessary to correct or ameliorate them
shall be performed by practitioners qualified to make those determinations
within their licensed scope of practice, either as a member of the IEP team or
by a qualified practitioner outside the IEP team.

a. Service providersProviders shall be employed
by the school division or under contract to the school division.

b. Supervision of services by providers recognized in
subdivision 4 of this subsection shall occur as allowed under federal
regulations and consistent with Virginia law, regulations, and DMAS provider
manuals.

c. The services described in subdivision 4 of this subsection
shall be delivered by school providers, but may also be available in the
community from other providers.

d. Services in this subsection are subject to utilization
control as provided under 42 CFR Parts 455 and 456.

e. The IEP shall determine whether or not the services
described in subdivision 4 of this subsection are medically necessary and that
the treatment prescribed is in accordance with standards of medical practice.
Medical necessity is defined as services ordered by IEP providers. The IEP
providers are qualified Medicaid providers to make the medical necessity
determination in accordance with their scope of practice. The services must be
described as to the amount, duration and scope.

4. Covered services include:

a. Physical therapy, occupational therapy and services for
individuals with speech, hearing, and language disorders, performed by, or
under the direction of, providers who meet the qualifications set forth at 42
CFR 440.110. This coverage includes audiology services.

b. Skilled nursing services are covered under 42 CFR 440.60.
These services are to be rendered in accordance to the licensing standards and
criteria of the Virginia Board of Nursing. Nursing services are to be provided
by licensed registered nurses or licensed practical nurses but may be delegated
by licensed registered nurses in accordance with the regulations of the Virginia
Board of Nursing, especially the section on delegation of nursing tasks and
procedures. The licensed practical nurse is under the supervision of a
registered nurse.

(1) The coverage of skilled nursing services shall be of a
level of complexity and sophistication (based on assessment, planning,
implementation and evaluation) that is consistent with skilled nursing services
when performed by a licensed registered nurse or a licensed practical nurse.
These skilled nursing services shall include [ , but not necessarily be
limited to ] dressing changes, maintaining patent airways, medication
administration/monitoring and urinary catheterizations.

(2) Skilled nursing services shall be directly and
specifically related to an active, written plan of care developed by a
registered nurse that is based on a written order from a physician, physician
assistant or nurse practitioner for skilled nursing services. This order shall
be recertified on an annual basis.

c. Psychiatric and psychological services performed by
licensed practitioners within the scope of practice are defined under state law
or regulations and covered as physicians' services under 42 CFR 440.50 or
medical or other remedial care under 42 CFR 440.60. These outpatient services
include individual medical psychotherapy, group medical psychotherapy coverage,
and family medical psychotherapy. Psychological and neuropsychological testing
are allowed when done for purposes other than educational diagnosis, school
admission, evaluation of an individual with intellectual disability prior to
admission to a nursing facility, or any placement issue. These services are
covered in the nonschool settings also. School providers who may render these
services when licensed by the state include psychiatrists, licensed clinical
psychologists, school psychologists, licensed clinical social workers,
professional counselors, psychiatric clinical nurse specialists, marriage and
family therapists, and school social workers.

d. Personal care services are covered under 42 CFR 440.167 and
performed by persons qualified under this subsection. The personal care
assistant is supervised by a DMAS recognized school-based health professional
who is acting within the scope of licensure. This practitioner develops a
written plan for meeting the needs of the child, which is implemented by the
assistant. The assistant must have qualifications comparable to those for other
personal care aides recognized by the Virginia Department of Medical Assistance
Services. The assistant performs services such as assisting with toileting,
ambulation, and eating. The assistant may serve as an aide on a specially
adapted school vehicle that enables transportation to or from the school or
school contracted provider on days when the student is receiving a
Medicaid-covered service under the IEP. Children requiring an aide during
transportation on a specially adapted vehicle shall have this stated in the
IEP.

e. Medical evaluation services are covered as physicians'
services under 42 CFR 440.50 or as medical or other remedial care under 42 CFR
440.60. Persons performing these services shall be licensed physicians,
physician assistants, or nurse practitioners. These practitioners shall
identify the nature or extent of a child's medical or other health related condition.

f. Transportation is covered as allowed under 42 CFR 431.53
and described at State Plan Attachment 3.1-D (12VAC30-50-530). Transportation
shall be rendered only by school division personnel or contractors.
Transportation is covered for a child who requires transportation on a
specially adapted school vehicle that enables transportation to or from the
school or school contracted provider on days when the student is receiving a
Medicaid-covered service under the IEP. Transportation shall be listed in the
child's IEP. Children requiring an aide during transportation on a specially
adapted vehicle shall have this stated in the IEP.

g. Assessments are covered as necessary to assess or reassess
the need for medical services in a child's IEP and shall be performed by any of
the above licensed practitioners within the scope of practice. Assessments and
reassessments not tied to medical needs of the child shall not be covered.

5. DMAS will ensure through quality management review that
duplication of services will be monitored. School divisions have a
responsibility to ensure that if a child is receiving additional therapy
outside of the school, that there will be coordination of services to avoid
duplication of service.

D. Family planning services and supplies for individuals of
child-bearing age.

1. Service must be ordered or prescribed and directed or
performed within the scope of the license of a practitioner of the healing arts.

2. Family planning services shall be defined as those services
that delay or prevent pregnancy. Coverage of such services shall not include
services to treat infertility or services to promote fertility. Family planning
services shall not cover payment for abortion services and no funds shall be
used to perform, assist, encourage, or make direct referrals for abortions.

3. Family planning services as established by
§ 1905(a)(4)(C) of the Social Security Act include annual family planning
exams; cervical cancer screening for women; sexually transmitted infection
(STI) testing; lab services for family planning and STI testing; family
planning education, counseling, and preconception health; sterilization
procedures; nonemergency transportation to a family planning service; and U.S.
Food and Drug Administration approved prescription and over-the-counter
contraceptives, subject to limits in 12VAC30-50-210.

12VAC30-60-61. Services related to the Early and Periodic
Screening, Diagnosis and Treatment Program (EPSDT); community mental health
[ and behavioral therapy ] services for children [ ;
behavioral therapy services for children ].

A. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context indicates
otherwise:

"At risk" means one or more of the following: (i)
within the two weeks before the intake, the individual shall be screened by an
LMHP for escalating behaviors that have put either the individual or others at
immediate risk of physical injury; (ii) the parent/guardian is unable to manage
the individual's mental, behavioral, or emotional problems in the home and is
actively, within the past two to four weeks, seeking an out-of-home placement;
(iii) a representative of either a juvenile justice agency, a department of
social services (either the state agency or local agency), a community services
board/behavioral health authority, the Department of Education, or an LMHP, as
defined in 12VAC35-105-20, and who is neither an employee of nor consultant to
the intensive in-home (IIH) services or therapeutic day treatment (TDT)
provider, has recommended an out-of-home placement absent an immediate change
of behaviors and when unsuccessful mental health services are evident; (iv) the
individual has a history of unsuccessful services (either crisis intervention,
crisis stabilization, outpatient psychotherapy, outpatient substance abuse
services, or mental health support) within the past 30 days; (v) the treatment
team or family assessment planning team (FAPT) recommends IIH services or TDT
for an individual currently who is either: (a) transitioning out of residential
treatment facility Level C services, (b) transitioning out of a group home
Level A or B services, (c) transitioning out of acute psychiatric
hospitalization, or (d) transitioning between foster homes, mental health case
management, crisis intervention, crisis stabilization, outpatient
psychotherapy, or outpatient substance abuse services.

"Failed services" or "unsuccessful
services" means, as measured by ongoing behavioral, mental, or physical
distress, that the [ service or ] services did not treat or
resolve the individual's mental health or behavioral issues.

"Individual" means the Medicaid-eligible person
receiving these services and for the purpose of this section includes children
from birth up to 12 years of age or adolescents ages 12 through 20 years.

"Licensed assistant behavior analyst" means a
person who has met the licensing requirements of 18VAC85-150 and holds a valid
license issued by the Department of Health Professions.

"Licensed behavior analyst" means a person who
has met the licensing requirements of 18VAC85-150 and holds a valid license
issued by the Department of Health Professions.

"New service" means a community mental health
rehabilitation service for which the individual does not have a current service
authorization in effect as of July 17, 2011.

"Out-of-home placement" means placement in one or
more of the following: (i) either a Level A or Level B group home; (ii) regular
foster home if the individual is currently residing with his biological family
and, due to his behavior problems, is at risk of being placed in the custody of
the local department of social services; (iii) treatment foster care if the
individual is currently residing with his biological family or a regular foster
care family and, due to the individual's behavioral problems, is at risk of
removal to a higher level of care; (iv) Level C residential facility; (v)
emergency shelter for the individual only due either to his mental health or
behavior or both; (vi) psychiatric hospitalization; or (vii) juvenile justice
system or incarceration.

"Service-specific provider intake" means the
evaluation that is conducted according to the Department of Medical Assistance
Services (DMAS) intake definition set out in 12VAC30-50-130.

B. Utilization review requirements for all services in
this section.

1. The services described in this section shall be
rendered consistent with the definitions, service limits, and requirements
described in this section and in 12VAC30-50-130.

2. Providers shall be required to refund payments made by
Medicaid if they fail to maintain adequate documentation to support billed
activities.

3. Individual service plans (ISPs) shall meet all of the
requirements set forth in 12VAC30-60-143 B 7.

C. IntensiveUtilization review of intensive
in-home (IIH) services for children and adolescents.

1. The service definition for intensive in-home (IIH) services
is contained in 12VAC30-50-130.

2. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from mental, behavioral or emotional
illness [ whichthat ] results in significant
functional impairments in major life activities. Individuals must meet at least
two of the following criteria on a continuing or intermittent basis to be
authorized for these services:

a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.

b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services or judicial system
are or have been necessary.

c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.

3. Prior to admission, an appropriate service-specific
provider intake, as defined in 12VAC30-50-130, shall be conducted by the
licensed mental health professional (LMHP), LMHP-supervisee, LMHP-resident, or
LMHP-RP, documenting the individual's diagnosis and describing how service
needs can best be met through intervention provided typically but not solely in
the individual's residence. The service-specific provider intake shall describe
how the individual's clinical needs put the individual at risk of out-of-home
placement and shall be conducted face-to-face in the individual's residence.
Claims for services that are based upon service-specific provider intakes that
are incomplete, outdated (more than 12 months old), or missing shall not be
reimbursed.

4. An individual service plan (ISP) shall be fully completed,
signed, and dated by either an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a
QMHP-C, or a QMHP-E and the individual and individual's parent/guardian within
30 days of initiation of services. The ISP shall meet all of the requirements
as defined in 12VAC30-50-226.

5. DMAS shall not reimburse for dates of services in which the
progress notes are not individualized and child-specific. Duplicated progress
notes shall not constitute the required child-specific individualized progress
notes. Each progress note shall demonstrate unique differences particular to
the individual's circumstances, treatment, and progress. Claim payments shall
be retracted for services that are supported by documentation that does not
demonstrate unique differences particular to the individual.

6. Services shall be directed toward the treatment of the
eligible individual and delivered primarily in the family's residence with the
individual present. As clinically indicated, the services may be rendered in
the community if there is documentation, on that date of service, of the
necessity of providing services in the community. The documentation shall
describe how the alternative community service location supports the identified
clinical needs of the individual and describe how it facilitates the implementation
of the ISP. For services provided outside of the home, there shall be
documentation reflecting therapeutic treatment as set forth in the ISP provided
for that date of service in the appropriately signed and dated progress notes.

7. These services shall be provided when the clinical needs of
the individual put him at risk for out-of-home placement, as these terms are
defined in this section:

a. When services that are far more intensive than outpatient
clinic care are required to stabilize the individual in the family situation,
or

b. When the individual's residence as the setting for services
is more likely to be successful than a clinic.

The service-specific provider intake shall describe how the
individual meets either subdivision a or b of this subdivision [ 7 ].

8. Services shall not be provided if the individual is no
longer a resident of the home.

9. Services shall also be used to facilitate the transition to
home from an out-of-home placement when services more intensive than outpatient
clinic care are required for the transition to be successful. The individual
and responsible parent/guardian shall be available and in agreement to
participate in the transition.

10. At least one parent/legal guardian or responsible adult
with whom the individual is living must be willing to participate in the
intensive in-home services with the goal of keeping the individual with the
family. In the instance of this service, a responsible adult shall be an adult
who lives in the same household with the child and is responsible for engaging
in therapy and service-related activities to benefit the individual.

11. The enrolled service provider shall be licensed by
the Department of Behavioral Health and Developmental Services (DBHDS) as a
provider of intensive in-home services. The provider shall also have a provider
enrollment agreement with DMAS or its contractor in effect prior to the
delivery of this service that indicates that the provider will offer intensive
in-home services.

12. Services must only be provided by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-C, or QMHP-E. Reimbursement shall
not be provided for such services when they have been rendered by a QPPMH as
defined in 12VAC35-105-20.

13. The billing unit for intensive in-home service shall be
one hour. Although the pattern of service delivery may vary, intensive in-home
services is an intensive service provided to individuals for whom there is an
ISP in effect which demonstrates the need for a minimum of three hours a week
of intensive in-home service, and includes a plan for service provision of a
minimum of three hours of service delivery per individual/family per week in
the initial phase of treatment. It is expected that the pattern of service
provision may show more intensive services and more frequent contact with the
individual and family initially with a lessening or tapering off of intensity
toward the latter weeks of service. Service plans shall incorporate an
individualized discharge plan that describes transition from intensive in-home
to less intensive or nonhome based services.

14. The ISP, as defined in 12VAC30-50-226, shall be updated as
the individual's needs and progress changes and signed by either the parent or
legal guardian and the individual. Documentation shall be provided if the
individual, who is a minor child, is unable or unwilling to sign the ISP. If
there is a lapse in services that is greater than 31 consecutive calendar days
without any communications from family members/legal guardian or the individual
with the service provider, the provider shall discharge the individual.
If the individual continues to need services, then a new intake/admission shall
be documented and a new service authorization shall be required.

15. The provider shall ensure that the maximum
staff-to-caseload ratio fully meets the needs of the individual.

16. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the service
provider shall contact the case manager and provide notification of the
provision of services. In addition, the provider shall send monthly updates to
the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 days of the service discontinuation date. Service
providersProviders and case managers who are using the same
electronic health record for the individual shall meet requirements for
delivery of the notification, monthly updates, and discharge summary upon entry
of the information in the electronic health records.

17. Emergency assistance shall be available 24 hours per day,
seven days a week.

19. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or guardian, shall
inform him of the individual's receipt of IIH services. The documentation shall
include who was contacted, when the contact occurred, and what information was
transmitted.

D. TherapeuticUtilization review of therapeutic
day treatment for children and adolescents.

1. The service definition for therapeutic day treatment (TDT)
for children and adolescents is contained in 12VAC30-50-130.

2. Therapeutic day treatment is appropriate for children and
adolescents who meet one of the following:

a. Children and adolescents who require year-round treatment in
order to sustain behavior or emotional gains.

b. Children and adolescents whose behavior and emotional
problems are so severe they cannot be handled in self-contained or resource
emotionally disturbed (ED) classrooms without:

(1) This programming during the school day; or

(2) This programming to supplement the school day or school
year.

c. Children and adolescents who would otherwise be placed on
homebound instruction because of severe emotional/behavior problems that
interfere with learning.

d. Children and adolescents who (i) have deficits in social
skills, peer relations or dealing with authority; (ii) are hyperactive; (iii)
have poor impulse control; (iv) are extremely depressed or marginally connected
with reality.

e. Children in preschool enrichment and early intervention
programs when the children's emotional/behavioral problems are so severe that
they cannot function in these programs without additional services.

3. The service-specific provider intake shall document the
individual's behavior and describe how the individual meets these specific
service criteria in subdivision 2 of this subsection.

4. Prior to admission to this service, a service-specific
provider intake shall be conducted by the LMHP as defined in 12VAC35-105-20.

5. An ISP shall be fully completed, signed, and dated by an
LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or QMHP-E and by the
individual or the parent/guardian within 30 days of initiation of services and
shall meet all requirements of an ISP as defined in 12VAC30-50-226. Individual
progress notes shall be required for each contact with the individual and shall
meet all of the requirements as defined in 12VAC30-50-130.

6. Such services shall not duplicate those services provided
by the school.

7. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from a condition due to mental,
behavioral or emotional illness [ whichthat ] results
in significant functional impairments in major life activities. Individuals
shall meet at least two of the following criteria on a continuing or
intermittent basis:

a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.

b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services, or judicial
system are or have been necessary.

c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.

8. The enrolled provider of therapeutic day treatment for child
and adolescent services shall be licensed by DBHDS to provide day support
services. The provider shall also have a provider enrollment agreement in
effect with DMAS prior to the delivery of this service that indicates that the
provider offers therapeutic day treatment services for children and
adolescents.

10. The minimum staff-to-individual ratio as defined by DBHDS
licensing requirements shall ensure that adequate staff is available to meet
the needs of the individual identified on the ISP.

11. The program shall operate a minimum of two hours per day
and may offer flexible program hours (i.e., before or after school or during
the summer). One unit of service shall be defined as a minimum of two hours but
less than three hours in a given day. Two units of service shall be defined as
a minimum of three but less than five hours in a given day. Three units of
service shall be defined as five or more hours of service in a given day.

12. Time required for academic instruction when no treatment
activity is going on shall not be included in the billing unit.

13. Services shall be provided following a service-specific
provider intake that is conducted by an LMHP, LMHP-supervisee, LMHP-resident,
or LMHP-RP. An LMHP, LMHP-supervisee, or LMHP-resident shall make and document
the diagnosis. The service-specific provider intake shall include the elements
as defined in 12VAC30-50-130.

14. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the provider
shall collaborate with the case manager and provide notification of the
provision of services. In addition, the provider shall send monthly updates to
the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 days of the service discontinuation date. Service
providersProviders and case managers using the same electronic
health record for the individual shall meet requirements for delivery of the
notification, monthly updates, and discharge summary upon entry of this
documentation into the electronic health record.

15. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
guardian, shall inform [ himthe primary care provider ]
of the child's receipt of community mental health rehabilitative services. The
documentation shall include who was contacted, when the contact occurred, and
what information was transmitted. The parent/legal guardian shall be required
to give written consent that this provider has permission to inform the primary
care provider of the child's or adolescent's receipt of community mental health
rehabilitative services.

16. Providers shall comply with DMAS marketing requirements as
set out in 12VAC30-130-2000. Providers that DMAS determines have violated these
marketing requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.

17. If there is a lapse in services greater than 31
consecutive calendar days, the provider shall discharge the individual. If the
individual continues to need services, a new intake/admission documentation
shall be prepared and a new service authorization shall be required.

E. Community-basedUtilization review of
community-based services for children and adolescents [ underyounger
than ] 21 years of age (Level A).

1. The staff ratio must be at least [ 1one ]
to [ 6six ] during the day and at least [ 1one ] to 10 between 11 p.m. and 7 a.m. The program director
supervising the program/group home must be, at minimum, a QMHP-C or QMHP-E (as
defined in 12VAC35-105-20). The program director must be employed full time.

2. In order for Medicaid reimbursement to be approved, at
least 50% of the provider's direct care staff at the group home must meet DBHDS
paraprofessional staff criteria, defined in 12VAC35-105-20.

3. Authorization is required for Medicaid reimbursement. All
community-based services for children and adolescents [ underyounger
than ] 21 (Level A) require authorization prior to reimbursement for
these services. Reimbursement shall not be made for this service when other
less intensive services may achieve stabilization.

4. Services must be provided in accordance with an individual
service plan (ISP), which must be fully completed within 30 days of
authorization for Medicaid reimbursement.

5. Prior to admission, a service-specific provider intake
shall be conducted according to DMAS specifications described in
12VAC30-50-130.

6. Such service-specific provider intakes shall be performed
by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.

7. If an individual receiving community-based services for
children and adolescents [ underyounger than ] 21
[ years of age ] (Level A) is also receiving case management
services, the provider shall collaborate with the case manager by notifying the
case manager of the provision of Level A services and shall send monthly
updates on the individual's progress. When the individual is discharged from
Level A services, a discharge summary shall be sent to the case manager within
30 days of the service discontinuation date. Service providersProviders
and case managers who are using the same electronic health record for the
individual shall meet requirements for the delivery of the notification,
monthly updates, and discharge summary upon entry of this documentation into
the electronic health record.

F. TherapeuticUtilization review of therapeutic
behavioral services for children and adolescents [ underyounger
than ] 21 years of age (Level B).

1. The staff ratio must be at least [ 1one ]
to [ 4four ] during the day and at least [ 1one ] to [ 8eight ] between 11 p.m. and 7
a.m. The clinical director must be a licensed mental health professional. The
caseload of the clinical director must not exceed 16 individuals including all
sites for which the same clinical director is responsible.

2. The program director must be full time and be a QMHP-C or
QMHP-E with a bachelor's degree and at least one year's clinical experience.

3. For Medicaid reimbursement to be approved, at least 50% of
the provider's direct care staff at the group home shall meet DBHDS
paraprofessional staff criteria, as defined in 12VAC35-105-20. The
program/group home must coordinate services with other providers.

4. All therapeutic behavioral services (Level B) shall be
authorized prior to reimbursement for these services. Services rendered without
such prior authorization shall not be covered.

5. Services must be provided in accordance with an ISP, which
shall be fully completed within 30 days of authorization for Medicaid
reimbursement.

6. Prior to admission, a service-specific provider intake
shall be performed using all elements specified by DMAS in 12VAC30-50-130.

7. Such service-specific provider intakes shall be performed
by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.

8. If an individual receiving therapeutic behavioral services
for children and adolescents [ underyounger than ] 21
[ years of age ] (Level B) is also receiving case management
services, the therapeutic behavioral services provider must collaborate with
the care coordinator/case manager by notifying him of the provision of Level B
services and the Level B services provider shall send monthly updates on the
individual's treatment status. When the individual is discharged from Level B
services, a discharge summary shall be sent to the care coordinator/case
manager within 30 days of the discontinuation date.

9. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
guardian, shall inform [ himthe primary care provider ]
of the individual's receipt of these Level B services. The documentation shall
include who was contacted, when the contact occurred, and what information was
transmitted. If these individuals are children or adolescents, then the
parent/legal guardian shall be required to give written consent that this
provider has permission to inform the primary care provider of the individual's
receipt of community mental health rehabilitative services.

G. Utilization review. Utilization reviews for
community-based services for children and adolescents [ underyounger
than ] 21 years of age (Level A) and therapeutic behavioral services
for children and adolescents [ underyounger than ] 21
years of age (Level B) shall include determinations whether providers meet all
DMAS requirements, including compliance with DMAS marketing requirements.
Providers that DMAS determines have violated the DMAS marketing requirements
shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000 E.

H. Utilization review of behavioral therapy services for
children.

1. In order for Medicaid to cover behavioral therapy
services, the provider shall be enrolled with DMAS or its contractor as a
Medicaid provider. The provider enrollment agreement shall be in effect prior
to the delivery of services for Medicaid reimbursement.

2. Behavioral therapy services shall be covered for
individuals younger than 21 years of age when recommended by the individual's
primary care provider, licensed physician, licensed physician assistant, or
licensed nurse practitioner and determined by DMAS or its contractor to be
medically necessary to correct or ameliorate significant impairments in major
life activities that have resulted from either developmental, behavioral, or
mental disabilities.

3. Behavioral therapy services require service
authorization. Services shall be authorized only when eligibility and medical
necessity criteria are met.

4. Prior to treatment, an appropriate service-specific
provider intake shall be conducted, documented, signed, and dated by a licensed
behavior analyst (LBA), licensed assistant behavior analyst (LABA), [ or ]
LMHP, LMHP-R, LMHP-RP, or LMHP-S, acting within the scope of his practice,
documenting the individual's diagnosis (including a description of the
[ behavior or ] behaviors targeted for treatment
with their frequency, duration, and intensity) and describing how service needs
can best be met through behavioral therapy. The service-specific provider
intake shall be conducted face-to-face in the individual's residence with the
individual and parent or guardian. [ A new service-specific
provider intake shall be conducted and documented every three months, or more
often if needed, annually to observe the individual and family
interaction, review clinical data, and revise the ISP as needed. ]

5. The ISP shall be developed upon admission to the service
and reviewed within 30 days of admission to the service to ensure that all
treatment goals are reflective of the individual's clinical needs and shall
describe each treatment goal, targeted behavior, one or more measurable
objectives for each targeted behavior, the behavioral modification strategy to
be used to manage each targeted behavior, the plan for parent or caregiver
training, care coordination, and the measurement and data collection methods to
be used for each targeted behavior in the ISP. The ISP [ as defined
in 12VAC30-50-130 ] shall be fully completed, signed, and dated by
an LBA, LABA, LMHP, LMHP-R, LMHP-RP, or LMHP-S [ and the
individual and individual's parent or guardian. The ISP shall be reviewed every
three months (at the same time the service-specific provider intake is
conducted and documented)and updated as the individual progresses and
his needs change, but at least annually, and shall be signed by either the
parent or legal guardian and the individual. Documentation shall be provided if
the individual, who is a minor child, is unable or unwilling to sign the ISP ].
[ Every three months, the LBA, LABA, LMHP, LMHP-R, LMHP-RP, or LMHP-S
shall review the ISP, modify the ISP as appropriate, and update the ISP, and
all of these activities shall occur with the individual in a manner in which
the individual may participate in the process. The ISP shall be rewritten at
least annually. ]

6. Reimbursement for the initial service-specific provider
intake and the initial ISP shall be limited to five hours without service
authorization. If additional time is needed to complete these documents,
service authorization shall be required.

7. Clinical supervision shall be required for Medicaid
reimbursement of behavioral therapy services that are rendered by an LABA,
LMHP-R, LMHP-RP, or LMHP-S or unlicensed staff consistent with the scope of
practice as described by the applicable Virginia Department of Health
Professions regulatory board. Clinical supervision [ of unlicensed
staff ] shall occur at least weekly [ and, as.
As ] documented in the individual's medical record, [ clinical
supervision ] shall include a review of progress notes and data and
dialogue with supervised staff about the individual's progress and the
effectiveness of the ISP. [ Clinical supervision shall be
documented by, at a minimum, the contemporaneously dated signature of the
clinical supervisor. ]

8. [ Family training involving the individual's
family and significant others to advance the treatment goals of the individual
shall be provided when (i) the training with the family member or significant
other is for the direct benefit of the individual, (ii) the training is not
aimed at addressing the treatment needs of the individual's family or
significant others, (iii) the individual is present except when it is
clinically appropriate for the individual to be absent in order to advance the
individual's treatment goals, and (iv) the training is aligned with the goals
of the individual's treatment plan.

9. ] The following shall not be covered under
this service:

a. Screening to identify physical, mental, or developmental
conditions that may require evaluation or treatment. Screening is covered as an
EPSDT service provided by the primary care provider and is not covered as a
behavioral therapy service under this section.

b. Services other than the initial service-specific
provider intake that are provided but are not based upon the individual's ISP
or linked to a service in the ISP. Time not actively involved in providing
services directed by the ISP shall not be reimbursed.

c. Services that are based upon an incomplete, missing, or
outdated service-specific provider intake or ISP.

d. Sessions that are conducted for family support,
education, recreational, or custodial purposes, including respite or child
care.

e. Services that are provided by a provider but are
rendered primarily by a relative or guardian who is legally responsible for the
individual's care.

f. Services that are provided in a clinic or provider's
office without documented justification for the location in the ISP.

g. Services that are provided in the absence of the
individual [ and or ] a parent or other
authorized caregiver identified in the ISP with the exception of treatment
review processes described in [ 12VAC30-60-61 H 11
subdivision 12 ] e [ of this subsection ],
care coordination, and clinical supervision.

h. Services provided by a local education agency.

i. Provider travel time.

[ 9. 10. ] Behavioral
therapy services shall not be reimbursed concurrently with community mental
health services described in 12VAC30-50-130 B 5 or 12VAC30-50-226, or
behavioral, psychological, or psychiatric therapeutic consultation described in
12VAC30-120-756, 12VAC30-120-1000, or 12VAC30-135-320.

[ 10. 11. ] If the
individual is receiving targeted case management services under the Medicaid
state plan (defined in 12VAC30-50-410 through 12VAC30-50-491, the provider
shall notify the case manager of the provision of behavioral therapy services
unless the parent or guardian requests that the information not be released. In
addition, the provider shall send monthly updates to the case manager on the
individual's status pursuant to a valid release of information. A discharge
summary shall be sent to the case manager within 30 days of the service
discontinuation date. A refusal of the parent or guardian to release
information shall be documented in the medical record for the date the request
was discussed.

[ 11. 12. ] Other standards
to ensure quality of services:

a. Services shall be delivered only by an LBA, LABA, LMHP,
LMHP-R, LMHP-RP, LMHP-S, or clinically supervised unlicensed staff consistent
with the scope of practice as described by the applicable Virginia Department
of Health Professions regulatory board.

b. Individual-specific services shall be directed toward
the treatment of the eligible individual and delivered in the family's
residence unless an alternative location is justified and documented in the
ISP.

c. Individual-specific progress notes shall be created
contemporaneously with the service activities and shall document the name and
Medicaid number of each individual; the provider's name, signature, and date;
and time of service. Documentation shall include activities provided, length of
services provided, the individual's reaction to that day's activity, and
documentation of the individual's and the parent or caregiver's progress toward
achieving each behavioral objective through analysis and reporting of
quantifiable behavioral data. Documentation shall be prepared to clearly
demonstrate efficacy using baseline and service-related data that shows
clinical progress and generalization for the child and family members toward
the therapy goals as defined in the service plan.

d. Documentation of all billed services shall include the
amount of time or billable units spent to deliver the service and shall be
signed and dated on the date of the service by the practitioner rendering the
service.

e. Billable time is permitted for the LBA, LABA, LMHP,
LMHP-R, LMHP-RP, or LMHP-S to better define behaviors and develop documentation
strategies to measure treatment performance and the efficacy of the ISP
objectives, provided that these activities are documented in a progress note as
described in subdivision [ 11 12 ] c of
this subsection.

[ 12. 13. ] Failure to
comply with any of the requirements in 12VAC30-50-130 or in this section shall
result in retraction.

A. Payment for behavioral therapy services for individuals
younger than 21 years of age shall be the lower of the state agency fee
schedule or actual charge (charge to the general public). All private and
governmental fee-for-service providers shall be reimbursed according to the
same methodology. The agency's rates were set as of October 1, 2011, and are
effective for services on or after that date until rates are revised. Rates are
published on the agency's website at http://www.dmas.virginia.gov/.

B. Providers shall be required to refund payments made by
Medicaid if they fail to maintain adequate documentation to support billed
activities.

12VAC30-120-380. MCO responsibilities.

EDITOR'S
NOTE: The proposed amendments to 12VAC30-120-380 were not adopted in the
final regulations; therefore, no changes are made this section.

A. The MCO shall provide, at a
minimum, all medically necessary covered services provided under the State Plan
for Medical Assistance and further defined by written DMAS regulations,
policies and instructions, except as otherwise modified or excluded in this
part.

1. Nonemergency services provided by hospital emergency
departments shall be covered by MCOs in accordance with rates negotiated
between the MCOs and the hospital emergency departments.

2. Services that shall be provided outside the MCO network
shall include [ , but are not limited to, ] those services identified
and defined by the contract between DMAS and the MCO. Services reimbursed by
DMAS include [ (i) ] dental and orthodontic services
for children up to age 21 [ years ]; [ (ii) ]
for all others, dental services (as described in 12VAC30-50-190); [ (iii) ]
school health services; [ (iv) ] community mental
health services (12VAC30-50-130 and 12VAC30-50-226); [ (v) ]
early intervention services provided pursuant to Part C of the Individuals with
Disabilities Education Act (IDEA) of 2004 (as defined in 12VAC30-50-131
[ and 12VAC30-50-415); and ); (vi) ] long-term care services
provided under the § 1915(c) home-based and community-based waivers including
related transportation to such authorized waiver services [ ; and
(vii) behavioral therapy services as defined in 12VAC30-50-130 ].

3. The MCOs shall pay for emergency services and family
planning services and supplies whether such services are provided inside or
outside the MCO network.

B. EPSDT services shall be covered by the MCO and defined by
the contract between DMAS and the MCO. The MCO shall have the authority to determine
the provider of service for EPSDT screenings.

C. The MCOs shall report data to DMAS under the contract
requirements, which may include data reports, report cards for members, and ad
hoc quality studies performed by the MCO or third parties.

D. Documentation requirements.

1. The MCO shall maintain records as required by federal and
state law and regulation and by DMAS policy. The MCO shall furnish such
required information to DMAS, the Attorney General of Virginia or his
authorized representatives, or the State Medicaid Fraud Control Unit on request
and in the form requested.

2. Each MCO shall have written policies regarding member
rights and shall comply with any applicable federal and state laws that pertain
to member rights and shall ensure that its staff and affiliated providers take
those rights into account when furnishing services to members in accordance
with 42 CFR 438.100.

[ 3. Providers shall be required to refund payments
if they fail to maintain adequate documentation to support billed activities. ]

E. The MCO shall ensure that the health care provided to its
members meets all applicable federal and state mandates, community standards
for quality, and standards developed pursuant to the DMAS managed care quality
program.

F. The MCOs shall promptly provide or arrange for the
provision of all required services as specified in the contract between the
Commonwealth and the MCO. Medical evaluations shall be available within 48
hours for urgent care and within 30 calendar days for routine care. On-call
clinicians shall be available 24 hours per day, seven days per week.

G. The MCOs shall meet standards specified by DMAS for
sufficiency of provider networks as specified in the contract between the
Commonwealth and the MCO.

H. Each MCO and its subcontractors shall have in place, and
follow, written policies and procedures for processing requests for initial and
continuing authorizations of service. Each MCO and its subcontractors shall
ensure that any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less than
requested, be made by a health care professional who has appropriate clinical
expertise in treating the member's condition or disease. Each MCO and its
subcontractors shall have in effect mechanisms to ensure consistent application
of review criteria for authorization decisions and shall consult with the
requesting provider when appropriate.

I. In accordance with 42 CFR 447.50 through 42 CFR 447.60,
MCOs shall not impose any cost sharing obligations on members except as set
forth in 12VAC30-20-150 and 12VAC30-20-160.

J. An MCO may not prohibit, or otherwise restrict, a health
care professional acting within the lawful scope of practice, from advising or
advocating on behalf of a member who is his patient in accordance with 42 CFR
438.102.

K. An MCO that would otherwise be required to reimburse for
or provide coverage of a counseling or referral service is not required to do
so if the MCO objects to the service on moral or religious grounds and
furnishes information about the service it does not cover in accordance with 42
CFR 438.102.

VA.R. Doc. No. R13-3527; Filed October 23, 2018, 10:33 a.m.

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Emergency Regulation

Title of Regulation: 12VAC30-60. Standards
Established and Methods Used to Assure High Quality Care (amending 12VAC30-60-5).

Section 2.2-4011 of the Code of Virginia states that
agencies may adopt emergency regulations in situations in which Virginia
statutory law or the appropriation act or federal law or federal regulation
requires that a regulation be effective in 280 days or less from its enactment,
and the regulation is not exempt under the provisions of § 2.2-4006 A 4 of the
Code of Virginia. Item 303 X of Chapter 2 of the 2018 Acts of the Assembly,
Special Session I, directs the agency to make changes to the utilization review
and provider qualifications for community mental health services in order to
ensure appropriate utilization and cost efficiency.

The amendments provide clarification to providers of the
documentation required to establish that services are rendered by individuals
with appropriate qualifications and credentials and update the regulations to
include Department of Health Professions requirements for registration of
qualified mental health professionals.

B. Some Medicaid covered services require an approved service
authorization prior to service delivery in order for reimbursement to occur. 1.
To obtain service authorization, all providers' information supplied to the
Department of Medical Assistance Services (DMAS), service authorization
contractor, or the behavioral health service authorization contractor shall be
fully substantiated throughout individuals' medical records.

2.C. Providers shall be required to maintain
documentation detailing all relevant information about the Medicaid individuals
who are in providers' care. Such documentation shall fully disclose the extent
of services provided in order to support providers' claims for reimbursement
for services rendered. This documentation shall be written, signed, and dated
at the time the services are rendered unless specified otherwise.

D. Providers shall maintain documentation that
demonstrates that individuals providing services have the required
qualifications established by DMAS, the Department of Health Professions (DHP),
or the Department of Behavioral Health and Developmental Services (DBHDS).

C.E. DMAS, or its designee, shall perform
reviews of the utilization of all Medicaid covered services pursuant to 42 CFR
440.260 and 42 CFR Part 456.

D.F. DMAS shall recover expenditures made for
covered services when providers' documentation does not comport with standards
specified in all applicable regulations.

E.G. Providers who are determined not to be in
compliance with DMAS requirements shall be subject to 12VAC30-80-130 for the
repayment of those overpayments to DMAS.

F.H. Utilization review requirements specific
to community mental health services, as set out in 12VAC30-50-130 and
12VAC30-50-226, shall be as follows:

1. To apply to be reimbursed as a Medicaid provider, the
required Department of Behavioral Health and Developmental Services (DBHDS)DHBDS license shall be either a full, annual, triennial, or conditional
license. Providers must be enrolled with DMAS or the BHSAbehavioral
health services administrator to be reimbursed. Once a health care entity
has been enrolled as a provider, it shall maintain, and update periodically as
DMAS requires, a current Provider Enrollment Agreement for each Medicaid
service that the provider offers.

2. Health care entities with provisional licenses issued by
DBHDS shall not be reimbursed as Medicaid providers of community mental
health services.

3. Payments shall not be permitted to health care entities
that either hold provisional licenses or fail to enter into a Medicaid Provider
Enrollment Agreement for a service prior to rendering that service.

4. The behavioral health service authorization contractor
shall apply a national standardized set of medical necessity criteria in use in
the industry, such as McKesson InterQual Criteria, or an equivalent standard
authorized in advance by DMAS. Services that fail to meet medical necessity
criteria shall be denied service authorization.

5. Service providers shall maintain documentation to
establish that services are rendered by individuals with appropriate
qualifications and credentials, including proof of licensure or registration
through DHP if applicable. Qualified mental health professional-eligibles shall
maintain documentation of supervision and of progress toward the requirements
for DHP registration as a qualified mental health professional-child or
progress toward the requirements for DHP registration as a qualified mental
health professional-adult.

The amendments establish Medicaid coverage for behavioral
therapy services for children under the authority of the Early and Periodic
Screening, Diagnosis and Treatment (EPSDT) program. EPSDT is a mandatory
Medicaid-covered service that offers preventive, diagnostic, and treatment
health care services to individuals from birth through the age 21 years. To be
covered for this service, an individual must have a psychiatric diagnosis
relevant to the need for behavioral therapy services, including autism, autism
spectrum disorders, or other similar developmental delays and must meet the
medical necessity criteria. The amendments define the behavioral therapy
service requirements, medical necessity criteria, provider clinical assessment
and intake procedures, service planning and progress measurement requirements,
care coordination, clinical supervision, and other standards to assure quality.
The behavioral therapy service will be reimbursed by the Department of Medical
Assistance Services outside of the Medallion 3 managed care contracts.

The proposed amendments to 12VAC30-120-180 were not adopted
in the final regulation; therefore, managed care organizations are allowed to
provide services. Changes in that section related to documentation will be
addressed in a separate regulatory action.

Summary of Public Comments and Agency's Response: A
summary of comments made by the public and the agency's response may be
obtained from the promulgating agency or viewed at the office of the Registrar
of Regulations.

12VAC30-50-130. Nursing facility services, EPSDT, including
school health services and family planning.

A. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
Service must be ordered or prescribed and directed or performed within the
scope of a license of the practitioner of the healing arts.

B. Early and periodic screening and diagnosis of individuals
younger than 21 years of age, and treatment of conditions found.

1. Payment of medical assistance services shall be made on
behalf of individuals younger than 21 years of age, who are Medicaid eligible,
for medically necessary stays in acute care facilities, and the accompanying
attendant physician care, in excess of 21 days per admission when such services
are rendered for the purpose of diagnosis and treatment of health conditions
identified through a physical examination.

2. Routine physicals and immunizations (except as provided
through EPSDT) are not covered except that well-child examinations in a private
physician's office are covered for foster children of the local social services
departments on specific referral from those departments.

3. Orthoptics services shall only be reimbursed if medically
necessary to correct a visual defect identified by an EPSDT examination or
evaluation. The department shall place appropriate utilization controls upon
this service.

4. Consistent with the Omnibus Budget Reconciliation Act of
1989 § 6403, early and periodic screening, diagnostic, and treatment services
means the following services: screening services, vision services, dental
services, hearing services, and such other necessary health care, diagnostic
services, treatment, and other measures described in Social Security Act §
1905(a) to correct or ameliorate defects and physical and mental illnesses and
conditions discovered by the screening services and [ whichthat ]
are medically necessary, whether or not such services are covered under the
State Plan and notwithstanding the limitations, applicable to recipients ages
21 years and older, provided for by § 1905(a) of the Social Security Act.

5. Community mental health services. These services in order to
be covered (i) shall meet medical necessity criteria based upon diagnoses made
by LMHPs who are practicing within the scope of their licenses and (ii) are
reflected in provider records and on providers' claims for services by
recognized diagnosis codes that support and are consistent with the requested
professional services.

a. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context clearly
indicates otherwise:

"Adolescent or child" means the individual receiving
the services described in this section. For the purpose of the use of these
terms, adolescent means an individual 12 through 20 years of age; a child means
an individual from birth up to 12 years of age.

"Behavioral health service" means the same as
defined in 12VAC30-130-5160.

"Behavioral health services administrator" or
"BHSA" means an entity that manages or directs a behavioral health
benefits program under contract with DMAS.

"Care coordination" means collaboration and sharing
of information among health care providers, who are involved with an
individual's health care, to improve the care.

"Caregiver" means the same as defined in
12VAC30-130-5160.

"Certified prescreener" means an employee of the
local community services board or behavioral health authority, or its designee,
who is skilled in the assessment and treatment of mental illness and has
completed a certification program approved by the Department of Behavioral
Health and Developmental Services.

"Clinical experience" means providing direct
behavioral health services on a full-time basis or equivalent hours of
part-time work to children and adolescents who have diagnoses of mental illness
and includes supervised internships, supervised practicums, and supervised
field experience for the purpose of Medicaid reimbursement of (i) intensive
in-home services, (ii) day treatment for children and adolescents, (iii)
community-based residential services for children and adolescents who are
younger than 21 years of age (Level A), or (iv) therapeutic behavioral services
(Level B). Experience shall not include unsupervised internships, unsupervised
practicums, and unsupervised field experience. The equivalency of part-time
hours to full-time hours for the purpose of this requirement shall be as
established by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.

"DBHDS" means the Department of Behavioral Health
and Developmental Services.

"Direct supervisor" means the person who provides
direct supervision to the peer recovery specialist. The direct supervisor (i) shall
have two consecutive years of documented practical experience rendering peer
support services or family support services, have certification training as a
PRS under a certifying body approved by DBHDS, and have documented completion
of the DBHDS PRS supervisor training; (ii) shall be a qualified mental health
professional (QMHP-A, QMHP-C, or QMHP-E) as defined in 12VAC35-105-20 with at
least two consecutive years of documented experience as a QMHP, and who has
documented completion of the DBHDS PRS supervisor training; or (iii) shall be
an LMHP who has documented completion of the DBHDS PRS supervisor training who
is acting within his scope of practice under state law. An LMHP providing
services before April 1, 2018, shall have until April 1, 2018, to complete the
DBHDS PRS supervisor training.

"DMAS" means the Department of Medical Assistance
Services and its [ contractor or ] contractors.

"EPSDT" means early and periodic screening,
diagnosis, and treatment.

"Family support partners" means the same as defined
in 12VAC30-130-5170.

"Human services field" means the same as the term is
defined by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.

"Individual service plan" or "ISP" means
the same as the term is defined in 12VAC30-50-226.

"Licensed mental health professional" or
"LMHP" means the same as defined in 12VAC35-105-20.

"LMHP-resident" or "LMHP-R" means the same
as "resident" as defined in (i) 18VAC115-20-10 for licensed
professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family
therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment
practitioners. An LMHP-resident shall be in continuous compliance with the
regulatory requirements of the applicable counseling profession for supervised
practice and shall not perform the functions of the LMHP-R or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Counseling. For purposes of Medicaid reimbursement to their supervisors for
services provided by such residents, they shall use the title
"Resident" in connection with the applicable profession after their
signatures to indicate such status.

"LMHP-resident in psychology" or "LMHP-RP"
means the same as an individual in a residency, as that term is defined in
18VAC125-20-10, program for clinical psychologists. An LMHP-resident in
psychology shall be in continuous compliance with the regulatory requirements
for supervised experience as found in 18VAC125-20-65 and shall not perform the
functions of the LMHP-RP or be considered a "resident" until the
supervision for specific clinical duties at a specific site has been
preapproved in writing by the Virginia Board of Psychology. For purposes of
Medicaid reimbursement by supervisors for services provided by such residents,
they shall use the title "Resident in Psychology" after their
signatures to indicate such status.

"LMHP-supervisee in social work,"
"LMHP-supervisee," or "LMHP-S" means the same as
"supervisee" as defined in 18VAC140-20-10 for licensed clinical
social workers. An LMHP-supervisee in social work shall be in continuous
compliance with the regulatory requirements for supervised practice as found in
18VAC140-20-50 and shall not perform the functions of the LMHP-S or be
considered a "supervisee" until the supervision for specific clinical
duties at a specific site is preapproved in writing by the Virginia Board of
Social Work. For purposes of Medicaid reimbursement to their supervisors for
services provided by supervisees, these persons shall use the title
"Supervisee in Social Work" after their signatures to indicate such
status.

"Peer recovery specialist" or "PRS" means
the same as defined in 12VAC30-130-5160.

"Person centered" means the same as defined in
12VAC30-130-5160.

"Progress notes" means individual-specific
documentation that contains the unique differences particular to the
individual's circumstances, treatment, and progress that is also signed and
contemporaneously dated by the provider's professional staff who have prepared
the notes. Individualized and member-specific progress notes are part of the
minimum documentation requirements and shall convey the individual's status, staff
interventions, and, as appropriate, the individual's progress, or lack of
progress, toward goals and objectives in the ISP. The progress notes shall also
include, at a minimum, the name of the service rendered, the date of the
service rendered, the signature and credentials of the person who rendered the
service, the setting in which the service was rendered, and the amount of time
or units/hours required to deliver the service. The content of each progress
note shall corroborate the time/units billed. Progress notes shall be
documented for each service that is billed.

"Psychoeducation" means (i) a specific form of
education aimed at helping individuals who have mental illness and their family
members or caregivers to access clear and concise information about mental
illness and (ii) a way of accessing and learning strategies to deal with mental
illness and its effects in order to design effective treatment plans and
strategies.

"Psychoeducational activities" means systematic
interventions based on supportive and cognitive behavior therapy that
emphasizes an individual's and his family's needs and focuses on increasing the
individual's and family's knowledge about mental disorders, adjusting to mental
illness, communicating and facilitating problem solving and increasing coping
skills.

"Qualified mental health professional-child" or
"QMHP-C" means the same as the term is defined in 12VAC35-105-20.

"Qualified mental health professional-eligible" or
"QMHP-E" means the same as the term is defined in 12VAC35-105-20 and
consistent with the requirements of 12VAC35-105-590.

"Qualified paraprofessional in mental health" or
"QPPMH" means the same as the term is defined in
12VAC35-105-20 and consistent with the requirements of 12VAC35-105-1370.

"Recovery-oriented services" means the same as
defined in 12VAC30-130-5160.

"Recovery, resiliency, and wellness plan" means the
same as defined in 12VAC30-130-5160.

"Resiliency" means the same as defined in
12VAC30-130-5160.

"Self-advocacy" means the same as defined in
12VAC30-130-5160.

"Service-specific provider intake" means the
face-to-face interaction in which the provider obtains information from the
child or adolescent, and parent or other family member [ or members ],
as appropriate, about the child's or adolescent's mental health status. It
includes documented history of the severity, intensity, and duration of mental
health care problems and issues and shall contain all of the following
elements: (i) the presenting issue/reason for referral, (ii) mental health history/hospitalizations,
(iii) previous interventions by providers and timeframes and response to
treatment, (iv) medical profile, (v) developmental history including history of
abuse, if appropriate, (vi) educational/vocational status, (vii) current living
situation and family history and relationships, (viii) legal status, (ix) drug
and alcohol profile, (x) resources and strengths, (xi) mental status exam and
profile, (xii) diagnosis, (xiii) professional summary and clinical formulation,
(xiv) recommended care and treatment goals, and (xv) the dated signature of the
LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP.

"Services provided under arrangement" means the same
as defined in 12VAC30-130-850.

"Strength-based" means the same as defined in
12VAC30-130-5160.

"Supervision" means the same as defined in
12VAC30-130-5160.

b. Intensive in-home services (IIH) to children and
adolescents [ under ageyounger than ] 21 [ years
of age ] shall be time-limited interventions provided in the
individual's residence and when clinically necessary in community settings. All
interventions and the settings of the intervention shall be defined in the
Individual Service Plan. All IIH services shall be designed to specifically
improve family dynamics, provide modeling, and the clinically necessary
interventions that increase functional and therapeutic interpersonal relations
between family members in the home. IIH services are designed to promote
psychoeducational benefits in the home setting of an individual who is at risk
of being moved into an out-of-home placement or who is being transitioned to
home from an out-of-home placement due to a documented medical need of the
individual. These services provide crisis treatment; individual and family
counseling; communication skills (e.g., counseling to assist the individual and
his parents or guardians, as appropriate, to understand and practice
appropriate problem solving, anger management, and interpersonal interaction,
etc.); care coordination with other required services; and 24-hour emergency
response.

(1) [ These services shall be limited annually to 26
weeks. ] Service authorization shall be required for Medicaid
reimbursement prior to the onset of services. Services rendered before the date
of authorization shall not be reimbursed.

[ (2) Service authorization shall be required for
services to continue beyond the initial 26 weeks.

(3)(2) ] Service-specific provider intakes
shall be required at the onset of services and ISPs shall be required during
the entire duration of services. Services based upon incomplete, missing, or
outdated service-specific provider intakes or ISPs shall be denied
reimbursement. Requirements for service-specific provider intakes and ISPs are
set out in this section.

[ (4)(3) ] These services may only be
rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a
QMHP-E.

c. Therapeutic day treatment (TDT) shall be provided two or
more hours per day in order to provide therapeutic interventions. Day treatment
programs [ , limited annually to 780 units, ] provide
evaluation; medication education and management; opportunities to learn and use
daily living skills and to enhance social and interpersonal skills (e.g.,
problem solving, anger management, community responsibility, increased impulse
control, and appropriate peer relations, etc.); and individual, group and
family counseling.

(1) Service authorization shall be required for Medicaid
reimbursement.

(2) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
service-specific provider intakes and ISPs are set out in this section.

(3) These services may be rendered only by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a QMHP-E.

d. Community-based services for children and adolescents
[ underyounger than ] 21 years of age (Level A)
pursuant to 42 CFR 440.031(d).

(1) Such services shall be a combination of therapeutic
services rendered in a residential setting. The residential services will
provide structure for daily activities, psychoeducation, therapeutic
supervision, care coordination, and psychiatric treatment to ensure the
attainment of therapeutic mental health goals as identified in the individual
service plan (plan of care). Individuals qualifying for this service must
demonstrate medical necessity for the service arising from a condition due to
mental, behavioral or emotional illness that results in significant functional
impairments in major life activities in the home, school, at work, or in the
community. The service must reasonably be expected to improve the child's
condition or prevent regression so that the services will no longer be needed.
The application of a national standardized set of medical necessity criteria in
use in the industry, such as McKesson InterQual® Criteria or an
equivalent standard authorized in advance by DMAS, shall be required for this
service.

(2) In addition to the residential services, the child must
receive, at least weekly, individual psychotherapy that is provided by an LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP.

(3) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.

(4) Authorization shall be required for Medicaid
reimbursement. Services that were rendered before the date of service
authorization shall not be reimbursed.

(5) Room and board costs shall not be reimbursed. DMAS shall
reimburse only for services provided in facilities or programs with no more
than 16 beds.

(6) These residential providers must be licensed by the
Department of Social Services, Department of Juvenile Justice, or Department of
Behavioral Health and Developmental Services under the Standards for Licensed
Children's Residential Facilities (22VAC40-151), Regulation Governing Juvenile
Group Homes and Halfway Houses (6VAC35-41), or Regulations for Children's
Residential Facilities (12VAC35-46).

(7) Daily progress notes shall document a minimum of seven
psychoeducational activities per week. Psychoeducational programming must
include [ , but is not limited to, ] development or
maintenance of daily living skills, anger management, social skills, family
living skills, communication skills, stress management, and any care
coordination activities.

(8) The facility/group home must coordinate services with
other providers. Such care coordination shall be documented in the individual's
medical record. The documentation shall include who was contacted, when the
contact occurred, and what information was transmitted.

(9) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
intakes and ISPs are set out in 12VAC30-60-61.

(10) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.

(1) Such services must be therapeutic services rendered in a
residential setting. The residential services will provide structure for daily
activities, psychoeducation, therapeutic supervision, care coordination, and
psychiatric treatment to ensure the attainment of therapeutic mental health
goals as identified in the individual service plan (plan of care). Individuals
qualifying for this service must demonstrate medical necessity for the service
arising from a condition due to mental, behavioral or emotional illness that
results in significant functional impairments in major life activities in the
home, school, at work, or in the community. The service must reasonably be
expected to improve the child's condition or prevent regression so that the
services will no longer be needed. The application of a national standardized
set of medical necessity criteria in use in the industry, such as McKesson
InterQual® Criteria, or an equivalent standard authorized in advance
by DMAS shall be required for this service.

(2) Authorization is required for Medicaid reimbursement.
Services that are rendered before the date of service authorization shall not
be reimbursed.

(3) Room and board costs shall not be reimbursed. Facilities
that only provide independent living services are not reimbursed. DMAS shall
reimburse only for services provided in facilities or programs with no more
than 16 beds.

(4) These residential providers must be licensed by the
Department of Behavioral Health and Developmental Services (DBHDS) under the
Regulations for Children's Residential Facilities (12VAC35-46).

(5) Daily progress notes shall document that a minimum of
seven psychoeducational activities per week occurs. Psychoeducational
programming must include [ , but is not limited to, ]
development or maintenance of daily living skills, anger management, social
skills, family living skills, communication skills, and stress management. This
service may be provided in a program setting or a community-based group home.

(6) The individual must receive, at least weekly, individual
psychotherapy and, at least weekly, group psychotherapy that is provided as
part of the program.

(7) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.

(8) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services that are based upon incomplete, missing, or outdated
service-specific provider intakes or ISPs shall be denied reimbursement.
Requirements for intakes and ISPs are set out in 12VAC30-60-61.

(9) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.

(10) The facility/group home shall coordinate necessary
services with other providers. Documentation of this care coordination shall be
maintained by the facility/group home in the individual's record. The
documentation shall include who was contacted, when the contact occurred, and
what information was transmitted.

f. Mental health family support partners.

(1) Mental health family support partners are peer recovery
support services and are nonclinical, peer-to-peer activities that engage,
educate, and support the caregiver and an individual's self-help efforts to
improve health recovery resiliency and wellness. Mental health family support partners
is a peer support service and is a strength-based, individualized service
provided to the caregiver of a Medicaid-eligible individual younger than 21
years of age with a mental health disorder that is the focus of support. The
services provided to the caregiver and individual must be directed exclusively
toward the benefit of the Medicaid-eligible individual. Services are expected
to improve outcomes for individuals younger than 21 years of age with complex
needs who are involved with multiple systems and increase the individual's and
family's confidence and capacity to manage their own services and supports
while promoting recovery and healthy relationships. These services are rendered
by a PRS who is (i) a parent of a minor or adult child with a similar mental
health disorder or (ii) an adult with personal experience with a family member
with a similar mental health disorder with experience navigating behavioral
health care services. The PRS shall perform the service within the scope of his
knowledge, lived experience, and education.

(2) Under the clinical oversight of the LMHP making the
recommendation for mental health family support partners, the peer recovery
specialist in consultation with his direct supervisor shall develop a recovery,
resiliency, and wellness plan based on the LMHP's recommendation for service,
the individual's and the caregiver's perceived recovery needs, and any clinical
assessments or service specific provider intakes as defined in this section
within 30 calendar days of the initiation of service. Development of the
recovery, resiliency, and wellness plan shall include collaboration with the
individual and the individual's caregiver. Individualized goals and strategies
shall be focused on the individual's identified needs for self-advocacy and
recovery. The recovery, resiliency, and wellness plan shall also include
documentation of how many days per week and how many hours per week are
required to carry out the services in order to meet the goals of the plan. The
recovery, resiliency, and wellness plan shall be completed, signed, and dated
by the LMHP, the PRS, the direct supervisor, the individual, and the
individual's caregiver within 30 calendar days of the initiation of service.
The PRS shall act as an advocate for the individual, encouraging the individual
and the caregiver to take a proactive role in developing and updating goals and
objectives in the individualized recovery planning.

(3) Documentation of required activities shall be required as
set forth in 12VAC30-130-5200 A and C through J.

(4) Limitations and exclusions to service delivery shall be
the same as set forth in 12VAC30-130-5210.

(5) Caregivers of individuals younger than 21 years of age who
qualify to receive mental health family support partners (i) care for an
individual with a mental health disorder who requires recovery assistance and
(ii) meet two or more of the following:

(a) Individual and his caregiver need peer-based
recovery-oriented services for the maintenance of wellness and the acquisition
of skills needed to support the individual.

(b) Individual and his caregiver need assistance to develop
self-advocacy skills to assist the individual in achieving self-management of
the individual's health status.

(c) Individual and his caregiver need assistance and support
to prepare the individual for a successful work or school experience.

(d) Individual and his caregiver need assistance to help the
individual and caregiver assume responsibility for recovery.

(6) Individuals 18 through 20 years of age who meet the
medical necessity criteria in 12VAC30-50-226 B 7 e, who would benefit from
receiving peer supports directly and who choose to receive mental health peer
support services directly instead of through their caregiver, shall be
permitted to receive mental health peer support services by an appropriate PRS.

(7) To qualify for continued mental health family support
partners, the requirements for continued services set forth in 12VAC30-130-5180
D shall be met.

(8) Discharge criteria from mental health family support
partners shall be the same as set forth in 12VAC30-130-5180 E.

(9) Mental health family support partners services shall be
rendered on an individual basis or in a group.

(10) Prior to service initiation, a documented recommendation
for mental health family support partners services shall be made by a licensed
mental health professional (LMHP) who is acting within his scope of practice
under state law. The recommendation shall verify that the individual meets the
medical necessity criteria set forth in subdivision 5 [ a (5) ]
of this subsection. The recommendation shall be valid for no longer than 30
calendar days.

(11) Effective July 1, 2017, a peer recovery specialist shall
have the qualifications, education, experience, and certification required by
DBHDS in order to be eligible to register with the Virginia Board of Counseling
on or after July 1, 2018. Upon the promulgation of regulations by the Board of
Counseling, registration of peer recovery specialists by the Board of
Counseling shall be required. The PRS shall perform mental health family
support partners services under the oversight of the LMHP making the
recommendation for services and providing the clinical oversight of the
recovery, resiliency, and wellness plan.

(12) The PRS shall be employed by or have a contractual
relationship with the enrolled provider licensed for one of the following:

(a) Acute care general and emergency department hospital
services licensed by the Department of Health.

(g) A community mental health and rehabilitative services
provider licensed by the Department of Behavioral Health and Developmental
Services as a provider of one of the following community mental health and
rehabilitative services as defined in this section, 12VAC30-50-226,
12VAC30-50-420, or 12VAC30-50-430 for which the individual younger than 21
years meets medical necessity criteria (i) intensive in home; (ii)
therapeutic day treatment; (iii) day treatment or partial hospitalization;
(iv) crisis intervention; (v) crisis stabilization; (vi) mental health skill
building; or (vii) mental health case management.

(13) Only the licensed and enrolled provider as referenced in
subdivision 5 f (12) of this subsection shall be eligible to bill and receive
reimbursement from DMAS or its contractor for mental health family support
partner services. Payments shall not be permitted to providers that fail to
enter into an enrollment agreement with DMAS or its contractor. Reimbursement
shall be subject to retraction for any billed service that is determined not to
be in compliance with DMAS requirements.

(14) Supervision of the PRS shall be required as set forth in
12VAC30-130-5190 E and 12VAC30-130-5200 G.

6. Inpatient psychiatric services shall be covered for
individuals younger than age 21 for medically necessary stays in inpatient
psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2) for the
purpose of diagnosis and treatment of mental health and behavioral disorders
identified under EPSDT when such services are rendered by (i) a psychiatric
hospital or an inpatient psychiatric program in a hospital accredited by the
Joint Commission on Accreditation of Healthcare Organizations; or (ii) a
psychiatric facility that is accredited by the Joint Commission on Accreditation
of Healthcare Organizations or the Commission on Accreditation of
Rehabilitation Facilities. Inpatient psychiatric hospital admissions at general
acute care hospitals and freestanding psychiatric hospitals shall also be
subject to the requirements of 12VAC30-50-100, 12VAC30-50-105, and
12VAC30-60-25. Inpatient psychiatric admissions to residential treatment
facilities shall also be subject to the requirements of Part XIV
(12VAC30-130-850 et seq.) of Amount, Duration and Scope of Selected Services.

a. The inpatient psychiatric services benefit for individuals
younger than 21 years of age shall include services defined at 42 CFR 440.160
that are provided under the direction of a physician pursuant to a
certification of medical necessity and plan of care developed by an
interdisciplinary team of professionals and shall involve active treatment
designed to achieve the child's discharge from inpatient status at the earliest
possible time. The inpatient psychiatric services benefit shall include
services provided under arrangement furnished by Medicaid enrolled providers
other than the inpatient psychiatric facility, as long as the inpatient
psychiatric facility (i) arranges for and oversees the provision of all
services, (ii) maintains all medical records of care furnished to the
individual, and (iii) ensures that the services are furnished under the
direction of a physician. Services provided under arrangement shall be
documented by a written referral from the inpatient psychiatric facility. For
purposes of pharmacy services, a prescription ordered by an employee or
contractor of the facility who is licensed to prescribe drugs shall be
considered the referral.

b. Eligible services provided under arrangement with the
inpatient psychiatric facility shall vary by provider type as described in this
subsection. For purposes of this section, emergency services means the same as
is set out in 12VAC30-50-310 B.

c. Inpatient psychiatric services are reimbursable only when
the treatment program is fully in compliance with (i) 42 CFR Part 441 Subpart
D, specifically 42 CFR 441.151(a) and (b) and [ 42 CFR ]
441.152 through [ 42 CFR ] 441.156, and (ii) the conditions of
participation in 42 CFR Part 483 Subpart G. Each admission must be
preauthorized and the treatment must meet DMAS requirements for clinical
necessity.

d. Service limits may be exceeded based on medical necessity
for individuals eligible for EPSDT.

7. Hearing aids shall be reimbursed for individuals younger
than 21 years of age according to medical necessity when provided by
practitioners licensed to engage in the practice of fitting or dealing in
hearing aids under the Code of Virginia.

9. Services facilitators shall be required for all consumer-directed
personal care services consistent with the requirements set out in
12VAC30-120-935.

10. Behavioral therapy services shall be covered for
individuals [ under the age of younger than ]
21 years [ of age ].

a. Definitions. The following words and terms when used in
this subsection shall have the following meanings unless the context clearly
indicates otherwise:

"Behavioral therapy" means systematic
interventions provided by licensed practitioners acting within the scope of
practice defined under a Virginia [ Department of ] Health
Professions [ Regulatory Board regulatory board ]
and covered as remedial care under 42 CFR 440.130(d) [ within
the home ] to individuals [ under
younger than ] 21 years of age. Behavioral therapy includes applied
behavioral analysis [ and is primarily provided in the family
home ]. Family [ counseling and ] training
related to the implementation of the behavioral therapy shall be included as
part of the behavioral therapy service. Behavioral therapy services shall be subject
to clinical reviews and determined as medically necessary. Behavioral therapy
may be [ intermittently ] provided in
[ the individual's home and ] community settings
[ when approved settings are as ] deemed by
DMAS or its contractor as medically necessary treatment.

[ "Counseling" means a professional mental
health service that can only be provided by a person holding a license issued
by a health regulatory board at the Department of Health Professions, which
includes conducting assessments, making diagnoses of mental disorders and
conditions, establishing treatment plans, and determining treatment
interventions. ]

"Individual" means the child or adolescent
[ under the age of younger than ] 21
[ years of age ] who is receiving behavioral therapy services.

"Primary care provider" means a licensed medical
practitioner who provides preventive and primary health care and is responsible
for providing routine EPSDT screening and referral and coordination of other
medical services needed by the individual.

b. Behavioral therapy services shall be designed to enhance
communication skills and decrease maladaptive patterns of behavior, which if
left untreated, could lead to more complex problems and the need for a greater
or a more intensive level of care. The service goal shall be to ensure the
individual's family or caregiver is trained to effectively manage the
individual's behavior in the home using modification strategies. [ The
All ] services shall be provided in accordance with the [ individual
service plan ISP ] and clinical assessment summary.

c. Behavioral therapy services shall be covered when
recommended by the individual's primary care provider or other licensed
physician, licensed physician assistant, or licensed nurse practitioner and
determined by DMAS or its contractor to be medically necessary to correct or
ameliorate significant impairments in major life activities that have resulted
from either developmental, behavioral, or mental disabilities. Criteria for
medical necessity are set out in 12VAC30-60-61 H. Service-specific provider
intakes shall be required at the onset of these services in order to receive
authorization for reimbursement. Individual service plans (ISPs) shall be
required throughout the entire duration of services. The services shall be
provided in accordance with the individual service plan and clinical assessment
summary. These services shall be provided in settings that are natural or
normal for a child or adolescent without a disability, such as [ his
the individual's ] home, unless there is justification in the ISP,
which has been authorized for reimbursement, to include service settings that
promote a generalization of behaviors across different settings to maintain the
targeted functioning outside of the treatment setting in the [ patient's
residence individual's home ] and the larger community
within which the individual resides. Covered behavioral therapy services shall
include:

2. School divisions may provide routine well-child screening
services under the State Plan. Diagnostic and treatment services that are
otherwise covered under early and periodic screening, diagnosis and treatment
services [ , ] shall not be covered for school divisions.
School divisions to receive reimbursement for the screenings shall be enrolled
with DMAS as clinic providers.

a. Children enrolled in managed care organizations shall
receive screenings from those organizations. School divisions shall not receive
reimbursement for screenings from DMAS for these children.

b. School-based services are listed in a recipient's
individualized education program (IEP) and covered under one or more of the
service categories described in § 1905(a) of the Social Security Act.
These services are necessary to correct or ameliorate defects of physical or
mental illnesses or conditions.

3. Service providersProviders shall be licensed
under the applicable state practice act or comparable licensing criteria by the
Virginia Department of Education [ , ] and shall meet
applicable qualifications under 42 CFR Part 440. Identification of defects,
illnesses or conditions and services necessary to correct or ameliorate them
shall be performed by practitioners qualified to make those determinations
within their licensed scope of practice, either as a member of the IEP team or
by a qualified practitioner outside the IEP team.

a. Service providersProviders shall be employed
by the school division or under contract to the school division.

b. Supervision of services by providers recognized in
subdivision 4 of this subsection shall occur as allowed under federal
regulations and consistent with Virginia law, regulations, and DMAS provider
manuals.

c. The services described in subdivision 4 of this subsection
shall be delivered by school providers, but may also be available in the
community from other providers.

d. Services in this subsection are subject to utilization
control as provided under 42 CFR Parts 455 and 456.

e. The IEP shall determine whether or not the services
described in subdivision 4 of this subsection are medically necessary and that
the treatment prescribed is in accordance with standards of medical practice.
Medical necessity is defined as services ordered by IEP providers. The IEP
providers are qualified Medicaid providers to make the medical necessity
determination in accordance with their scope of practice. The services must be
described as to the amount, duration and scope.

4. Covered services include:

a. Physical therapy, occupational therapy and services for
individuals with speech, hearing, and language disorders, performed by, or
under the direction of, providers who meet the qualifications set forth at 42
CFR 440.110. This coverage includes audiology services.

b. Skilled nursing services are covered under 42 CFR 440.60.
These services are to be rendered in accordance to the licensing standards and
criteria of the Virginia Board of Nursing. Nursing services are to be provided
by licensed registered nurses or licensed practical nurses but may be delegated
by licensed registered nurses in accordance with the regulations of the Virginia
Board of Nursing, especially the section on delegation of nursing tasks and
procedures. The licensed practical nurse is under the supervision of a
registered nurse.

(1) The coverage of skilled nursing services shall be of a
level of complexity and sophistication (based on assessment, planning,
implementation and evaluation) that is consistent with skilled nursing services
when performed by a licensed registered nurse or a licensed practical nurse.
These skilled nursing services shall include [ , but not necessarily be
limited to ] dressing changes, maintaining patent airways, medication
administration/monitoring and urinary catheterizations.

(2) Skilled nursing services shall be directly and
specifically related to an active, written plan of care developed by a
registered nurse that is based on a written order from a physician, physician
assistant or nurse practitioner for skilled nursing services. This order shall
be recertified on an annual basis.

c. Psychiatric and psychological services performed by
licensed practitioners within the scope of practice are defined under state law
or regulations and covered as physicians' services under 42 CFR 440.50 or
medical or other remedial care under 42 CFR 440.60. These outpatient services
include individual medical psychotherapy, group medical psychotherapy coverage,
and family medical psychotherapy. Psychological and neuropsychological testing
are allowed when done for purposes other than educational diagnosis, school
admission, evaluation of an individual with intellectual disability prior to
admission to a nursing facility, or any placement issue. These services are
covered in the nonschool settings also. School providers who may render these
services when licensed by the state include psychiatrists, licensed clinical
psychologists, school psychologists, licensed clinical social workers,
professional counselors, psychiatric clinical nurse specialists, marriage and
family therapists, and school social workers.

d. Personal care services are covered under 42 CFR 440.167 and
performed by persons qualified under this subsection. The personal care
assistant is supervised by a DMAS recognized school-based health professional
who is acting within the scope of licensure. This practitioner develops a
written plan for meeting the needs of the child, which is implemented by the
assistant. The assistant must have qualifications comparable to those for other
personal care aides recognized by the Virginia Department of Medical Assistance
Services. The assistant performs services such as assisting with toileting,
ambulation, and eating. The assistant may serve as an aide on a specially
adapted school vehicle that enables transportation to or from the school or
school contracted provider on days when the student is receiving a
Medicaid-covered service under the IEP. Children requiring an aide during
transportation on a specially adapted vehicle shall have this stated in the
IEP.

e. Medical evaluation services are covered as physicians'
services under 42 CFR 440.50 or as medical or other remedial care under 42 CFR
440.60. Persons performing these services shall be licensed physicians,
physician assistants, or nurse practitioners. These practitioners shall
identify the nature or extent of a child's medical or other health related condition.

f. Transportation is covered as allowed under 42 CFR 431.53
and described at State Plan Attachment 3.1-D (12VAC30-50-530). Transportation
shall be rendered only by school division personnel or contractors.
Transportation is covered for a child who requires transportation on a
specially adapted school vehicle that enables transportation to or from the
school or school contracted provider on days when the student is receiving a
Medicaid-covered service under the IEP. Transportation shall be listed in the
child's IEP. Children requiring an aide during transportation on a specially
adapted vehicle shall have this stated in the IEP.

g. Assessments are covered as necessary to assess or reassess
the need for medical services in a child's IEP and shall be performed by any of
the above licensed practitioners within the scope of practice. Assessments and
reassessments not tied to medical needs of the child shall not be covered.

5. DMAS will ensure through quality management review that
duplication of services will be monitored. School divisions have a
responsibility to ensure that if a child is receiving additional therapy
outside of the school, that there will be coordination of services to avoid
duplication of service.

D. Family planning services and supplies for individuals of
child-bearing age.

1. Service must be ordered or prescribed and directed or
performed within the scope of the license of a practitioner of the healing arts.

2. Family planning services shall be defined as those services
that delay or prevent pregnancy. Coverage of such services shall not include
services to treat infertility or services to promote fertility. Family planning
services shall not cover payment for abortion services and no funds shall be
used to perform, assist, encourage, or make direct referrals for abortions.

3. Family planning services as established by
§ 1905(a)(4)(C) of the Social Security Act include annual family planning
exams; cervical cancer screening for women; sexually transmitted infection
(STI) testing; lab services for family planning and STI testing; family
planning education, counseling, and preconception health; sterilization
procedures; nonemergency transportation to a family planning service; and U.S.
Food and Drug Administration approved prescription and over-the-counter
contraceptives, subject to limits in 12VAC30-50-210.

12VAC30-60-61. Services related to the Early and Periodic
Screening, Diagnosis and Treatment Program (EPSDT); community mental health
[ and behavioral therapy ] services for children [ ;
behavioral therapy services for children ].

A. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context indicates
otherwise:

"At risk" means one or more of the following: (i)
within the two weeks before the intake, the individual shall be screened by an
LMHP for escalating behaviors that have put either the individual or others at
immediate risk of physical injury; (ii) the parent/guardian is unable to manage
the individual's mental, behavioral, or emotional problems in the home and is
actively, within the past two to four weeks, seeking an out-of-home placement;
(iii) a representative of either a juvenile justice agency, a department of
social services (either the state agency or local agency), a community services
board/behavioral health authority, the Department of Education, or an LMHP, as
defined in 12VAC35-105-20, and who is neither an employee of nor consultant to
the intensive in-home (IIH) services or therapeutic day treatment (TDT)
provider, has recommended an out-of-home placement absent an immediate change
of behaviors and when unsuccessful mental health services are evident; (iv) the
individual has a history of unsuccessful services (either crisis intervention,
crisis stabilization, outpatient psychotherapy, outpatient substance abuse
services, or mental health support) within the past 30 days; (v) the treatment
team or family assessment planning team (FAPT) recommends IIH services or TDT
for an individual currently who is either: (a) transitioning out of residential
treatment facility Level C services, (b) transitioning out of a group home
Level A or B services, (c) transitioning out of acute psychiatric
hospitalization, or (d) transitioning between foster homes, mental health case
management, crisis intervention, crisis stabilization, outpatient
psychotherapy, or outpatient substance abuse services.

"Failed services" or "unsuccessful
services" means, as measured by ongoing behavioral, mental, or physical
distress, that the [ service or ] services did not treat or
resolve the individual's mental health or behavioral issues.

"Individual" means the Medicaid-eligible person
receiving these services and for the purpose of this section includes children
from birth up to 12 years of age or adolescents ages 12 through 20 years.

"Licensed assistant behavior analyst" means a
person who has met the licensing requirements of 18VAC85-150 and holds a valid
license issued by the Department of Health Professions.

"Licensed behavior analyst" means a person who
has met the licensing requirements of 18VAC85-150 and holds a valid license
issued by the Department of Health Professions.

"New service" means a community mental health
rehabilitation service for which the individual does not have a current service
authorization in effect as of July 17, 2011.

"Out-of-home placement" means placement in one or
more of the following: (i) either a Level A or Level B group home; (ii) regular
foster home if the individual is currently residing with his biological family
and, due to his behavior problems, is at risk of being placed in the custody of
the local department of social services; (iii) treatment foster care if the
individual is currently residing with his biological family or a regular foster
care family and, due to the individual's behavioral problems, is at risk of
removal to a higher level of care; (iv) Level C residential facility; (v)
emergency shelter for the individual only due either to his mental health or
behavior or both; (vi) psychiatric hospitalization; or (vii) juvenile justice
system or incarceration.

"Service-specific provider intake" means the
evaluation that is conducted according to the Department of Medical Assistance
Services (DMAS) intake definition set out in 12VAC30-50-130.

B. Utilization review requirements for all services in
this section.

1. The services described in this section shall be
rendered consistent with the definitions, service limits, and requirements
described in this section and in 12VAC30-50-130.

2. Providers shall be required to refund payments made by
Medicaid if they fail to maintain adequate documentation to support billed
activities.

3. Individual service plans (ISPs) shall meet all of the
requirements set forth in 12VAC30-60-143 B 7.

C. IntensiveUtilization review of intensive
in-home (IIH) services for children and adolescents.

1. The service definition for intensive in-home (IIH) services
is contained in 12VAC30-50-130.

2. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from mental, behavioral or emotional
illness [ whichthat ] results in significant
functional impairments in major life activities. Individuals must meet at least
two of the following criteria on a continuing or intermittent basis to be
authorized for these services:

a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.

b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services or judicial system
are or have been necessary.

c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.

3. Prior to admission, an appropriate service-specific
provider intake, as defined in 12VAC30-50-130, shall be conducted by the
licensed mental health professional (LMHP), LMHP-supervisee, LMHP-resident, or
LMHP-RP, documenting the individual's diagnosis and describing how service
needs can best be met through intervention provided typically but not solely in
the individual's residence. The service-specific provider intake shall describe
how the individual's clinical needs put the individual at risk of out-of-home
placement and shall be conducted face-to-face in the individual's residence.
Claims for services that are based upon service-specific provider intakes that
are incomplete, outdated (more than 12 months old), or missing shall not be
reimbursed.

4. An individual service plan (ISP) shall be fully completed,
signed, and dated by either an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a
QMHP-C, or a QMHP-E and the individual and individual's parent/guardian within
30 days of initiation of services. The ISP shall meet all of the requirements
as defined in 12VAC30-50-226.

5. DMAS shall not reimburse for dates of services in which the
progress notes are not individualized and child-specific. Duplicated progress
notes shall not constitute the required child-specific individualized progress
notes. Each progress note shall demonstrate unique differences particular to
the individual's circumstances, treatment, and progress. Claim payments shall
be retracted for services that are supported by documentation that does not
demonstrate unique differences particular to the individual.

6. Services shall be directed toward the treatment of the
eligible individual and delivered primarily in the family's residence with the
individual present. As clinically indicated, the services may be rendered in
the community if there is documentation, on that date of service, of the
necessity of providing services in the community. The documentation shall
describe how the alternative community service location supports the identified
clinical needs of the individual and describe how it facilitates the implementation
of the ISP. For services provided outside of the home, there shall be
documentation reflecting therapeutic treatment as set forth in the ISP provided
for that date of service in the appropriately signed and dated progress notes.

7. These services shall be provided when the clinical needs of
the individual put him at risk for out-of-home placement, as these terms are
defined in this section:

a. When services that are far more intensive than outpatient
clinic care are required to stabilize the individual in the family situation,
or

b. When the individual's residence as the setting for services
is more likely to be successful than a clinic.

The service-specific provider intake shall describe how the
individual meets either subdivision a or b of this subdivision [ 7 ].

8. Services shall not be provided if the individual is no
longer a resident of the home.

9. Services shall also be used to facilitate the transition to
home from an out-of-home placement when services more intensive than outpatient
clinic care are required for the transition to be successful. The individual
and responsible parent/guardian shall be available and in agreement to
participate in the transition.

10. At least one parent/legal guardian or responsible adult
with whom the individual is living must be willing to participate in the
intensive in-home services with the goal of keeping the individual with the
family. In the instance of this service, a responsible adult shall be an adult
who lives in the same household with the child and is responsible for engaging
in therapy and service-related activities to benefit the individual.

11. The enrolled service provider shall be licensed by
the Department of Behavioral Health and Developmental Services (DBHDS) as a
provider of intensive in-home services. The provider shall also have a provider
enrollment agreement with DMAS or its contractor in effect prior to the
delivery of this service that indicates that the provider will offer intensive
in-home services.

12. Services must only be provided by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-C, or QMHP-E. Reimbursement shall
not be provided for such services when they have been rendered by a QPPMH as
defined in 12VAC35-105-20.

13. The billing unit for intensive in-home service shall be
one hour. Although the pattern of service delivery may vary, intensive in-home
services is an intensive service provided to individuals for whom there is an
ISP in effect which demonstrates the need for a minimum of three hours a week
of intensive in-home service, and includes a plan for service provision of a
minimum of three hours of service delivery per individual/family per week in
the initial phase of treatment. It is expected that the pattern of service
provision may show more intensive services and more frequent contact with the
individual and family initially with a lessening or tapering off of intensity
toward the latter weeks of service. Service plans shall incorporate an
individualized discharge plan that describes transition from intensive in-home
to less intensive or nonhome based services.

14. The ISP, as defined in 12VAC30-50-226, shall be updated as
the individual's needs and progress changes and signed by either the parent or
legal guardian and the individual. Documentation shall be provided if the
individual, who is a minor child, is unable or unwilling to sign the ISP. If
there is a lapse in services that is greater than 31 consecutive calendar days
without any communications from family members/legal guardian or the individual
with the service provider, the provider shall discharge the individual.
If the individual continues to need services, then a new intake/admission shall
be documented and a new service authorization shall be required.

15. The provider shall ensure that the maximum
staff-to-caseload ratio fully meets the needs of the individual.

16. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the service
provider shall contact the case manager and provide notification of the
provision of services. In addition, the provider shall send monthly updates to
the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 days of the service discontinuation date. Service
providersProviders and case managers who are using the same
electronic health record for the individual shall meet requirements for
delivery of the notification, monthly updates, and discharge summary upon entry
of the information in the electronic health records.

17. Emergency assistance shall be available 24 hours per day,
seven days a week.

19. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or guardian, shall
inform him of the individual's receipt of IIH services. The documentation shall
include who was contacted, when the contact occurred, and what information was
transmitted.

D. TherapeuticUtilization review of therapeutic
day treatment for children and adolescents.

1. The service definition for therapeutic day treatment (TDT)
for children and adolescents is contained in 12VAC30-50-130.

2. Therapeutic day treatment is appropriate for children and
adolescents who meet one of the following:

a. Children and adolescents who require year-round treatment in
order to sustain behavior or emotional gains.

b. Children and adolescents whose behavior and emotional
problems are so severe they cannot be handled in self-contained or resource
emotionally disturbed (ED) classrooms without:

(1) This programming during the school day; or

(2) This programming to supplement the school day or school
year.

c. Children and adolescents who would otherwise be placed on
homebound instruction because of severe emotional/behavior problems that
interfere with learning.

d. Children and adolescents who (i) have deficits in social
skills, peer relations or dealing with authority; (ii) are hyperactive; (iii)
have poor impulse control; (iv) are extremely depressed or marginally connected
with reality.

e. Children in preschool enrichment and early intervention
programs when the children's emotional/behavioral problems are so severe that
they cannot function in these programs without additional services.

3. The service-specific provider intake shall document the
individual's behavior and describe how the individual meets these specific
service criteria in subdivision 2 of this subsection.

4. Prior to admission to this service, a service-specific
provider intake shall be conducted by the LMHP as defined in 12VAC35-105-20.

5. An ISP shall be fully completed, signed, and dated by an
LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or QMHP-E and by the
individual or the parent/guardian within 30 days of initiation of services and
shall meet all requirements of an ISP as defined in 12VAC30-50-226. Individual
progress notes shall be required for each contact with the individual and shall
meet all of the requirements as defined in 12VAC30-50-130.

6. Such services shall not duplicate those services provided
by the school.

7. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from a condition due to mental,
behavioral or emotional illness [ whichthat ] results
in significant functional impairments in major life activities. Individuals
shall meet at least two of the following criteria on a continuing or
intermittent basis:

a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.

b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services, or judicial
system are or have been necessary.

c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.

8. The enrolled provider of therapeutic day treatment for child
and adolescent services shall be licensed by DBHDS to provide day support
services. The provider shall also have a provider enrollment agreement in
effect with DMAS prior to the delivery of this service that indicates that the
provider offers therapeutic day treatment services for children and
adolescents.

10. The minimum staff-to-individual ratio as defined by DBHDS
licensing requirements shall ensure that adequate staff is available to meet
the needs of the individual identified on the ISP.

11. The program shall operate a minimum of two hours per day
and may offer flexible program hours (i.e., before or after school or during
the summer). One unit of service shall be defined as a minimum of two hours but
less than three hours in a given day. Two units of service shall be defined as
a minimum of three but less than five hours in a given day. Three units of
service shall be defined as five or more hours of service in a given day.

12. Time required for academic instruction when no treatment
activity is going on shall not be included in the billing unit.

13. Services shall be provided following a service-specific
provider intake that is conducted by an LMHP, LMHP-supervisee, LMHP-resident,
or LMHP-RP. An LMHP, LMHP-supervisee, or LMHP-resident shall make and document
the diagnosis. The service-specific provider intake shall include the elements
as defined in 12VAC30-50-130.

14. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the provider
shall collaborate with the case manager and provide notification of the
provision of services. In addition, the provider shall send monthly updates to
the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 days of the service discontinuation date. Service
providersProviders and case managers using the same electronic
health record for the individual shall meet requirements for delivery of the
notification, monthly updates, and discharge summary upon entry of this
documentation into the electronic health record.

15. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
guardian, shall inform [ himthe primary care provider ]
of the child's receipt of community mental health rehabilitative services. The
documentation shall include who was contacted, when the contact occurred, and
what information was transmitted. The parent/legal guardian shall be required
to give written consent that this provider has permission to inform the primary
care provider of the child's or adolescent's receipt of community mental health
rehabilitative services.

16. Providers shall comply with DMAS marketing requirements as
set out in 12VAC30-130-2000. Providers that DMAS determines have violated these
marketing requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.

17. If there is a lapse in services greater than 31
consecutive calendar days, the provider shall discharge the individual. If the
individual continues to need services, a new intake/admission documentation
shall be prepared and a new service authorization shall be required.

E. Community-basedUtilization review of
community-based services for children and adolescents [ underyounger
than ] 21 years of age (Level A).

1. The staff ratio must be at least [ 1one ]
to [ 6six ] during the day and at least [ 1one ] to 10 between 11 p.m. and 7 a.m. The program director
supervising the program/group home must be, at minimum, a QMHP-C or QMHP-E (as
defined in 12VAC35-105-20). The program director must be employed full time.

2. In order for Medicaid reimbursement to be approved, at
least 50% of the provider's direct care staff at the group home must meet DBHDS
paraprofessional staff criteria, defined in 12VAC35-105-20.

3. Authorization is required for Medicaid reimbursement. All
community-based services for children and adolescents [ underyounger
than ] 21 (Level A) require authorization prior to reimbursement for
these services. Reimbursement shall not be made for this service when other
less intensive services may achieve stabilization.

4. Services must be provided in accordance with an individual
service plan (ISP), which must be fully completed within 30 days of
authorization for Medicaid reimbursement.

5. Prior to admission, a service-specific provider intake
shall be conducted according to DMAS specifications described in
12VAC30-50-130.

6. Such service-specific provider intakes shall be performed
by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.

7. If an individual receiving community-based services for
children and adolescents [ underyounger than ] 21
[ years of age ] (Level A) is also receiving case management
services, the provider shall collaborate with the case manager by notifying the
case manager of the provision of Level A services and shall send monthly
updates on the individual's progress. When the individual is discharged from
Level A services, a discharge summary shall be sent to the case manager within
30 days of the service discontinuation date. Service providersProviders
and case managers who are using the same electronic health record for the
individual shall meet requirements for the delivery of the notification,
monthly updates, and discharge summary upon entry of this documentation into
the electronic health record.

F. TherapeuticUtilization review of therapeutic
behavioral services for children and adolescents [ underyounger
than ] 21 years of age (Level B).

1. The staff ratio must be at least [ 1one ]
to [ 4four ] during the day and at least [ 1one ] to [ 8eight ] between 11 p.m. and 7
a.m. The clinical director must be a licensed mental health professional. The
caseload of the clinical director must not exceed 16 individuals including all
sites for which the same clinical director is responsible.

2. The program director must be full time and be a QMHP-C or
QMHP-E with a bachelor's degree and at least one year's clinical experience.

3. For Medicaid reimbursement to be approved, at least 50% of
the provider's direct care staff at the group home shall meet DBHDS
paraprofessional staff criteria, as defined in 12VAC35-105-20. The
program/group home must coordinate services with other providers.

4. All therapeutic behavioral services (Level B) shall be
authorized prior to reimbursement for these services. Services rendered without
such prior authorization shall not be covered.

5. Services must be provided in accordance with an ISP, which
shall be fully completed within 30 days of authorization for Medicaid
reimbursement.

6. Prior to admission, a service-specific provider intake
shall be performed using all elements specified by DMAS in 12VAC30-50-130.

7. Such service-specific provider intakes shall be performed
by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.

8. If an individual receiving therapeutic behavioral services
for children and adolescents [ underyounger than ] 21
[ years of age ] (Level B) is also receiving case management
services, the therapeutic behavioral services provider must collaborate with
the care coordinator/case manager by notifying him of the provision of Level B
services and the Level B services provider shall send monthly updates on the
individual's treatment status. When the individual is discharged from Level B
services, a discharge summary shall be sent to the care coordinator/case
manager within 30 days of the discontinuation date.

9. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
guardian, shall inform [ himthe primary care provider ]
of the individual's receipt of these Level B services. The documentation shall
include who was contacted, when the contact occurred, and what information was
transmitted. If these individuals are children or adolescents, then the
parent/legal guardian shall be required to give written consent that this
provider has permission to inform the primary care provider of the individual's
receipt of community mental health rehabilitative services.

G. Utilization review. Utilization reviews for
community-based services for children and adolescents [ underyounger
than ] 21 years of age (Level A) and therapeutic behavioral services
for children and adolescents [ underyounger than ] 21
years of age (Level B) shall include determinations whether providers meet all
DMAS requirements, including compliance with DMAS marketing requirements.
Providers that DMAS determines have violated the DMAS marketing requirements
shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000 E.

H. Utilization review of behavioral therapy services for
children.

1. In order for Medicaid to cover behavioral therapy
services, the provider shall be enrolled with DMAS or its contractor as a
Medicaid provider. The provider enrollment agreement shall be in effect prior
to the delivery of services for Medicaid reimbursement.

2. Behavioral therapy services shall be covered for
individuals younger than 21 years of age when recommended by the individual's
primary care provider, licensed physician, licensed physician assistant, or
licensed nurse practitioner and determined by DMAS or its contractor to be
medically necessary to correct or ameliorate significant impairments in major
life activities that have resulted from either developmental, behavioral, or
mental disabilities.

3. Behavioral therapy services require service
authorization. Services shall be authorized only when eligibility and medical
necessity criteria are met.

4. Prior to treatment, an appropriate service-specific
provider intake shall be conducted, documented, signed, and dated by a licensed
behavior analyst (LBA), licensed assistant behavior analyst (LABA), [ or ]
LMHP, LMHP-R, LMHP-RP, or LMHP-S, acting within the scope of his practice,
documenting the individual's diagnosis (including a description of the
[ behavior or ] behaviors targeted for treatment
with their frequency, duration, and intensity) and describing how service needs
can best be met through behavioral therapy. The service-specific provider
intake shall be conducted face-to-face in the individual's residence with the
individual and parent or guardian. [ A new service-specific
provider intake shall be conducted and documented every three months, or more
often if needed, annually to observe the individual and family
interaction, review clinical data, and revise the ISP as needed. ]

5. The ISP shall be developed upon admission to the service
and reviewed within 30 days of admission to the service to ensure that all
treatment goals are reflective of the individual's clinical needs and shall
describe each treatment goal, targeted behavior, one or more measurable
objectives for each targeted behavior, the behavioral modification strategy to
be used to manage each targeted behavior, the plan for parent or caregiver
training, care coordination, and the measurement and data collection methods to
be used for each targeted behavior in the ISP. The ISP [ as defined
in 12VAC30-50-130 ] shall be fully completed, signed, and dated by
an LBA, LABA, LMHP, LMHP-R, LMHP-RP, or LMHP-S [ and the
individual and individual's parent or guardian. The ISP shall be reviewed every
three months (at the same time the service-specific provider intake is
conducted and documented)and updated as the individual progresses and
his needs change, but at least annually, and shall be signed by either the
parent or legal guardian and the individual. Documentation shall be provided if
the individual, who is a minor child, is unable or unwilling to sign the ISP ].
[ Every three months, the LBA, LABA, LMHP, LMHP-R, LMHP-RP, or LMHP-S
shall review the ISP, modify the ISP as appropriate, and update the ISP, and
all of these activities shall occur with the individual in a manner in which
the individual may participate in the process. The ISP shall be rewritten at
least annually. ]

6. Reimbursement for the initial service-specific provider
intake and the initial ISP shall be limited to five hours without service
authorization. If additional time is needed to complete these documents,
service authorization shall be required.

7. Clinical supervision shall be required for Medicaid
reimbursement of behavioral therapy services that are rendered by an LABA,
LMHP-R, LMHP-RP, or LMHP-S or unlicensed staff consistent with the scope of
practice as described by the applicable Virginia Department of Health
Professions regulatory board. Clinical supervision [ of unlicensed
staff ] shall occur at least weekly [ and, as.
As ] documented in the individual's medical record, [ clinical
supervision ] shall include a review of progress notes and data and
dialogue with supervised staff about the individual's progress and the
effectiveness of the ISP. [ Clinical supervision shall be
documented by, at a minimum, the contemporaneously dated signature of the
clinical supervisor. ]

8. [ Family training involving the individual's
family and significant others to advance the treatment goals of the individual
shall be provided when (i) the training with the family member or significant
other is for the direct benefit of the individual, (ii) the training is not
aimed at addressing the treatment needs of the individual's family or
significant others, (iii) the individual is present except when it is
clinically appropriate for the individual to be absent in order to advance the
individual's treatment goals, and (iv) the training is aligned with the goals
of the individual's treatment plan.

9. ] The following shall not be covered under
this service:

a. Screening to identify physical, mental, or developmental
conditions that may require evaluation or treatment. Screening is covered as an
EPSDT service provided by the primary care provider and is not covered as a
behavioral therapy service under this section.

b. Services other than the initial service-specific
provider intake that are provided but are not based upon the individual's ISP
or linked to a service in the ISP. Time not actively involved in providing
services directed by the ISP shall not be reimbursed.

c. Services that are based upon an incomplete, missing, or
outdated service-specific provider intake or ISP.

d. Sessions that are conducted for family support,
education, recreational, or custodial purposes, including respite or child
care.

e. Services that are provided by a provider but are
rendered primarily by a relative or guardian who is legally responsible for the
individual's care.

f. Services that are provided in a clinic or provider's
office without documented justification for the location in the ISP.

g. Services that are provided in the absence of the
individual [ and or ] a parent or other
authorized caregiver identified in the ISP with the exception of treatment
review processes described in [ 12VAC30-60-61 H 11
subdivision 12 ] e [ of this subsection ],
care coordination, and clinical supervision.

h. Services provided by a local education agency.

i. Provider travel time.

[ 9. 10. ] Behavioral
therapy services shall not be reimbursed concurrently with community mental
health services described in 12VAC30-50-130 B 5 or 12VAC30-50-226, or
behavioral, psychological, or psychiatric therapeutic consultation described in
12VAC30-120-756, 12VAC30-120-1000, or 12VAC30-135-320.

[ 10. 11. ] If the
individual is receiving targeted case management services under the Medicaid
state plan (defined in 12VAC30-50-410 through 12VAC30-50-491, the provider
shall notify the case manager of the provision of behavioral therapy services
unless the parent or guardian requests that the information not be released. In
addition, the provider shall send monthly updates to the case manager on the
individual's status pursuant to a valid release of information. A discharge
summary shall be sent to the case manager within 30 days of the service
discontinuation date. A refusal of the parent or guardian to release
information shall be documented in the medical record for the date the request
was discussed.

[ 11. 12. ] Other standards
to ensure quality of services:

a. Services shall be delivered only by an LBA, LABA, LMHP,
LMHP-R, LMHP-RP, LMHP-S, or clinically supervised unlicensed staff consistent
with the scope of practice as described by the applicable Virginia Department
of Health Professions regulatory board.

b. Individual-specific services shall be directed toward
the treatment of the eligible individual and delivered in the family's
residence unless an alternative location is justified and documented in the
ISP.

c. Individual-specific progress notes shall be created
contemporaneously with the service activities and shall document the name and
Medicaid number of each individual; the provider's name, signature, and date;
and time of service. Documentation shall include activities provided, length of
services provided, the individual's reaction to that day's activity, and
documentation of the individual's and the parent or caregiver's progress toward
achieving each behavioral objective through analysis and reporting of
quantifiable behavioral data. Documentation shall be prepared to clearly
demonstrate efficacy using baseline and service-related data that shows
clinical progress and generalization for the child and family members toward
the therapy goals as defined in the service plan.

d. Documentation of all billed services shall include the
amount of time or billable units spent to deliver the service and shall be
signed and dated on the date of the service by the practitioner rendering the
service.

e. Billable time is permitted for the LBA, LABA, LMHP,
LMHP-R, LMHP-RP, or LMHP-S to better define behaviors and develop documentation
strategies to measure treatment performance and the efficacy of the ISP
objectives, provided that these activities are documented in a progress note as
described in subdivision [ 11 12 ] c of
this subsection.

[ 12. 13. ] Failure to
comply with any of the requirements in 12VAC30-50-130 or in this section shall
result in retraction.

A. Payment for behavioral therapy services for individuals
younger than 21 years of age shall be the lower of the state agency fee
schedule or actual charge (charge to the general public). All private and
governmental fee-for-service providers shall be reimbursed according to the
same methodology. The agency's rates were set as of October 1, 2011, and are
effective for services on or after that date until rates are revised. Rates are
published on the agency's website at http://www.dmas.virginia.gov/.

B. Providers shall be required to refund payments made by
Medicaid if they fail to maintain adequate documentation to support billed
activities.

12VAC30-120-380. MCO responsibilities.

EDITOR'S
NOTE: The proposed amendments to 12VAC30-120-380 were not adopted in the
final regulations; therefore, no changes are made this section.

A. The MCO shall provide, at a
minimum, all medically necessary covered services provided under the State Plan
for Medical Assistance and further defined by written DMAS regulations,
policies and instructions, except as otherwise modified or excluded in this
part.

1. Nonemergency services provided by hospital emergency
departments shall be covered by MCOs in accordance with rates negotiated
between the MCOs and the hospital emergency departments.

2. Services that shall be provided outside the MCO network
shall include [ , but are not limited to, ] those services identified
and defined by the contract between DMAS and the MCO. Services reimbursed by
DMAS include [ (i) ] dental and orthodontic services
for children up to age 21 [ years ]; [ (ii) ]
for all others, dental services (as described in 12VAC30-50-190); [ (iii) ]
school health services; [ (iv) ] community mental
health services (12VAC30-50-130 and 12VAC30-50-226); [ (v) ]
early intervention services provided pursuant to Part C of the Individuals with
Disabilities Education Act (IDEA) of 2004 (as defined in 12VAC30-50-131
[ and 12VAC30-50-415); and ); (vi) ] long-term care services
provided under the § 1915(c) home-based and community-based waivers including
related transportation to such authorized waiver services [ ; and
(vii) behavioral therapy services as defined in 12VAC30-50-130 ].

3. The MCOs shall pay for emergency services and family
planning services and supplies whether such services are provided inside or
outside the MCO network.

B. EPSDT services shall be covered by the MCO and defined by
the contract between DMAS and the MCO. The MCO shall have the authority to determine
the provider of service for EPSDT screenings.

C. The MCOs shall report data to DMAS under the contract
requirements, which may include data reports, report cards for members, and ad
hoc quality studies performed by the MCO or third parties.

D. Documentation requirements.

1. The MCO shall maintain records as required by federal and
state law and regulation and by DMAS policy. The MCO shall furnish such
required information to DMAS, the Attorney General of Virginia or his
authorized representatives, or the State Medicaid Fraud Control Unit on request
and in the form requested.

2. Each MCO shall have written policies regarding member
rights and shall comply with any applicable federal and state laws that pertain
to member rights and shall ensure that its staff and affiliated providers take
those rights into account when furnishing services to members in accordance
with 42 CFR 438.100.

[ 3. Providers shall be required to refund payments
if they fail to maintain adequate documentation to support billed activities. ]

E. The MCO shall ensure that the health care provided to its
members meets all applicable federal and state mandates, community standards
for quality, and standards developed pursuant to the DMAS managed care quality
program.

F. The MCOs shall promptly provide or arrange for the
provision of all required services as specified in the contract between the
Commonwealth and the MCO. Medical evaluations shall be available within 48
hours for urgent care and within 30 calendar days for routine care. On-call
clinicians shall be available 24 hours per day, seven days per week.

G. The MCOs shall meet standards specified by DMAS for
sufficiency of provider networks as specified in the contract between the
Commonwealth and the MCO.

H. Each MCO and its subcontractors shall have in place, and
follow, written policies and procedures for processing requests for initial and
continuing authorizations of service. Each MCO and its subcontractors shall
ensure that any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less than
requested, be made by a health care professional who has appropriate clinical
expertise in treating the member's condition or disease. Each MCO and its
subcontractors shall have in effect mechanisms to ensure consistent application
of review criteria for authorization decisions and shall consult with the
requesting provider when appropriate.

I. In accordance with 42 CFR 447.50 through 42 CFR 447.60,
MCOs shall not impose any cost sharing obligations on members except as set
forth in 12VAC30-20-150 and 12VAC30-20-160.

J. An MCO may not prohibit, or otherwise restrict, a health
care professional acting within the lawful scope of practice, from advising or
advocating on behalf of a member who is his patient in accordance with 42 CFR
438.102.

K. An MCO that would otherwise be required to reimburse for
or provide coverage of a counseling or referral service is not required to do
so if the MCO objects to the service on moral or religious grounds and
furnishes information about the service it does not cover in accordance with 42
CFR 438.102.

The amendments establish Medicaid coverage for behavioral
therapy services for children under the authority of the Early and Periodic
Screening, Diagnosis and Treatment (EPSDT) program. EPSDT is a mandatory
Medicaid-covered service that offers preventive, diagnostic, and treatment
health care services to individuals from birth through the age 21 years. To be
covered for this service, an individual must have a psychiatric diagnosis
relevant to the need for behavioral therapy services, including autism, autism
spectrum disorders, or other similar developmental delays and must meet the
medical necessity criteria. The amendments define the behavioral therapy
service requirements, medical necessity criteria, provider clinical assessment
and intake procedures, service planning and progress measurement requirements,
care coordination, clinical supervision, and other standards to assure quality.
The behavioral therapy service will be reimbursed by the Department of Medical
Assistance Services outside of the Medallion 3 managed care contracts.

The proposed amendments to 12VAC30-120-180 were not adopted
in the final regulation; therefore, managed care organizations are allowed to
provide services. Changes in that section related to documentation will be
addressed in a separate regulatory action.

Summary of Public Comments and Agency's Response: A
summary of comments made by the public and the agency's response may be
obtained from the promulgating agency or viewed at the office of the Registrar
of Regulations.

12VAC30-50-130. Nursing facility services, EPSDT, including
school health services and family planning.

A. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
Service must be ordered or prescribed and directed or performed within the
scope of a license of the practitioner of the healing arts.

B. Early and periodic screening and diagnosis of individuals
younger than 21 years of age, and treatment of conditions found.

1. Payment of medical assistance services shall be made on
behalf of individuals younger than 21 years of age, who are Medicaid eligible,
for medically necessary stays in acute care facilities, and the accompanying
attendant physician care, in excess of 21 days per admission when such services
are rendered for the purpose of diagnosis and treatment of health conditions
identified through a physical examination.

2. Routine physicals and immunizations (except as provided
through EPSDT) are not covered except that well-child examinations in a private
physician's office are covered for foster children of the local social services
departments on specific referral from those departments.

3. Orthoptics services shall only be reimbursed if medically
necessary to correct a visual defect identified by an EPSDT examination or
evaluation. The department shall place appropriate utilization controls upon
this service.

4. Consistent with the Omnibus Budget Reconciliation Act of
1989 § 6403, early and periodic screening, diagnostic, and treatment services
means the following services: screening services, vision services, dental
services, hearing services, and such other necessary health care, diagnostic
services, treatment, and other measures described in Social Security Act §
1905(a) to correct or ameliorate defects and physical and mental illnesses and
conditions discovered by the screening services and [ whichthat ]
are medically necessary, whether or not such services are covered under the
State Plan and notwithstanding the limitations, applicable to recipients ages
21 years and older, provided for by § 1905(a) of the Social Security Act.

5. Community mental health services. These services in order to
be covered (i) shall meet medical necessity criteria based upon diagnoses made
by LMHPs who are practicing within the scope of their licenses and (ii) are
reflected in provider records and on providers' claims for services by
recognized diagnosis codes that support and are consistent with the requested
professional services.

a. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context clearly
indicates otherwise:

"Adolescent or child" means the individual receiving
the services described in this section. For the purpose of the use of these
terms, adolescent means an individual 12 through 20 years of age; a child means
an individual from birth up to 12 years of age.

"Behavioral health service" means the same as
defined in 12VAC30-130-5160.

"Behavioral health services administrator" or
"BHSA" means an entity that manages or directs a behavioral health
benefits program under contract with DMAS.

"Care coordination" means collaboration and sharing
of information among health care providers, who are involved with an
individual's health care, to improve the care.

"Caregiver" means the same as defined in
12VAC30-130-5160.

"Certified prescreener" means an employee of the
local community services board or behavioral health authority, or its designee,
who is skilled in the assessment and treatment of mental illness and has
completed a certification program approved by the Department of Behavioral
Health and Developmental Services.

"Clinical experience" means providing direct
behavioral health services on a full-time basis or equivalent hours of
part-time work to children and adolescents who have diagnoses of mental illness
and includes supervised internships, supervised practicums, and supervised
field experience for the purpose of Medicaid reimbursement of (i) intensive
in-home services, (ii) day treatment for children and adolescents, (iii)
community-based residential services for children and adolescents who are
younger than 21 years of age (Level A), or (iv) therapeutic behavioral services
(Level B). Experience shall not include unsupervised internships, unsupervised
practicums, and unsupervised field experience. The equivalency of part-time
hours to full-time hours for the purpose of this requirement shall be as
established by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.

"DBHDS" means the Department of Behavioral Health
and Developmental Services.

"Direct supervisor" means the person who provides
direct supervision to the peer recovery specialist. The direct supervisor (i) shall
have two consecutive years of documented practical experience rendering peer
support services or family support services, have certification training as a
PRS under a certifying body approved by DBHDS, and have documented completion
of the DBHDS PRS supervisor training; (ii) shall be a qualified mental health
professional (QMHP-A, QMHP-C, or QMHP-E) as defined in 12VAC35-105-20 with at
least two consecutive years of documented experience as a QMHP, and who has
documented completion of the DBHDS PRS supervisor training; or (iii) shall be
an LMHP who has documented completion of the DBHDS PRS supervisor training who
is acting within his scope of practice under state law. An LMHP providing
services before April 1, 2018, shall have until April 1, 2018, to complete the
DBHDS PRS supervisor training.

"DMAS" means the Department of Medical Assistance
Services and its [ contractor or ] contractors.

"EPSDT" means early and periodic screening,
diagnosis, and treatment.

"Family support partners" means the same as defined
in 12VAC30-130-5170.

"Human services field" means the same as the term is
defined by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.

"Individual service plan" or "ISP" means
the same as the term is defined in 12VAC30-50-226.

"Licensed mental health professional" or
"LMHP" means the same as defined in 12VAC35-105-20.

"LMHP-resident" or "LMHP-R" means the same
as "resident" as defined in (i) 18VAC115-20-10 for licensed
professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family
therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment
practitioners. An LMHP-resident shall be in continuous compliance with the
regulatory requirements of the applicable counseling profession for supervised
practice and shall not perform the functions of the LMHP-R or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Counseling. For purposes of Medicaid reimbursement to their supervisors for
services provided by such residents, they shall use the title
"Resident" in connection with the applicable profession after their
signatures to indicate such status.

"LMHP-resident in psychology" or "LMHP-RP"
means the same as an individual in a residency, as that term is defined in
18VAC125-20-10, program for clinical psychologists. An LMHP-resident in
psychology shall be in continuous compliance with the regulatory requirements
for supervised experience as found in 18VAC125-20-65 and shall not perform the
functions of the LMHP-RP or be considered a "resident" until the
supervision for specific clinical duties at a specific site has been
preapproved in writing by the Virginia Board of Psychology. For purposes of
Medicaid reimbursement by supervisors for services provided by such residents,
they shall use the title "Resident in Psychology" after their
signatures to indicate such status.

"LMHP-supervisee in social work,"
"LMHP-supervisee," or "LMHP-S" means the same as
"supervisee" as defined in 18VAC140-20-10 for licensed clinical
social workers. An LMHP-supervisee in social work shall be in continuous
compliance with the regulatory requirements for supervised practice as found in
18VAC140-20-50 and shall not perform the functions of the LMHP-S or be
considered a "supervisee" until the supervision for specific clinical
duties at a specific site is preapproved in writing by the Virginia Board of
Social Work. For purposes of Medicaid reimbursement to their supervisors for
services provided by supervisees, these persons shall use the title
"Supervisee in Social Work" after their signatures to indicate such
status.

"Peer recovery specialist" or "PRS" means
the same as defined in 12VAC30-130-5160.

"Person centered" means the same as defined in
12VAC30-130-5160.

"Progress notes" means individual-specific
documentation that contains the unique differences particular to the
individual's circumstances, treatment, and progress that is also signed and
contemporaneously dated by the provider's professional staff who have prepared
the notes. Individualized and member-specific progress notes are part of the
minimum documentation requirements and shall convey the individual's status, staff
interventions, and, as appropriate, the individual's progress, or lack of
progress, toward goals and objectives in the ISP. The progress notes shall also
include, at a minimum, the name of the service rendered, the date of the
service rendered, the signature and credentials of the person who rendered the
service, the setting in which the service was rendered, and the amount of time
or units/hours required to deliver the service. The content of each progress
note shall corroborate the time/units billed. Progress notes shall be
documented for each service that is billed.

"Psychoeducation" means (i) a specific form of
education aimed at helping individuals who have mental illness and their family
members or caregivers to access clear and concise information about mental
illness and (ii) a way of accessing and learning strategies to deal with mental
illness and its effects in order to design effective treatment plans and
strategies.

"Psychoeducational activities" means systematic
interventions based on supportive and cognitive behavior therapy that
emphasizes an individual's and his family's needs and focuses on increasing the
individual's and family's knowledge about mental disorders, adjusting to mental
illness, communicating and facilitating problem solving and increasing coping
skills.

"Qualified mental health professional-child" or
"QMHP-C" means the same as the term is defined in 12VAC35-105-20.

"Qualified mental health professional-eligible" or
"QMHP-E" means the same as the term is defined in 12VAC35-105-20 and
consistent with the requirements of 12VAC35-105-590.

"Qualified paraprofessional in mental health" or
"QPPMH" means the same as the term is defined in
12VAC35-105-20 and consistent with the requirements of 12VAC35-105-1370.

"Recovery-oriented services" means the same as
defined in 12VAC30-130-5160.

"Recovery, resiliency, and wellness plan" means the
same as defined in 12VAC30-130-5160.

"Resiliency" means the same as defined in
12VAC30-130-5160.

"Self-advocacy" means the same as defined in
12VAC30-130-5160.

"Service-specific provider intake" means the
face-to-face interaction in which the provider obtains information from the
child or adolescent, and parent or other family member [ or members ],
as appropriate, about the child's or adolescent's mental health status. It
includes documented history of the severity, intensity, and duration of mental
health care problems and issues and shall contain all of the following
elements: (i) the presenting issue/reason for referral, (ii) mental health history/hospitalizations,
(iii) previous interventions by providers and timeframes and response to
treatment, (iv) medical profile, (v) developmental history including history of
abuse, if appropriate, (vi) educational/vocational status, (vii) current living
situation and family history and relationships, (viii) legal status, (ix) drug
and alcohol profile, (x) resources and strengths, (xi) mental status exam and
profile, (xii) diagnosis, (xiii) professional summary and clinical formulation,
(xiv) recommended care and treatment goals, and (xv) the dated signature of the
LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP.

"Services provided under arrangement" means the same
as defined in 12VAC30-130-850.

"Strength-based" means the same as defined in
12VAC30-130-5160.

"Supervision" means the same as defined in
12VAC30-130-5160.

b. Intensive in-home services (IIH) to children and
adolescents [ under ageyounger than ] 21 [ years
of age ] shall be time-limited interventions provided in the
individual's residence and when clinically necessary in community settings. All
interventions and the settings of the intervention shall be defined in the
Individual Service Plan. All IIH services shall be designed to specifically
improve family dynamics, provide modeling, and the clinically necessary
interventions that increase functional and therapeutic interpersonal relations
between family members in the home. IIH services are designed to promote
psychoeducational benefits in the home setting of an individual who is at risk
of being moved into an out-of-home placement or who is being transitioned to
home from an out-of-home placement due to a documented medical need of the
individual. These services provide crisis treatment; individual and family
counseling; communication skills (e.g., counseling to assist the individual and
his parents or guardians, as appropriate, to understand and practice
appropriate problem solving, anger management, and interpersonal interaction,
etc.); care coordination with other required services; and 24-hour emergency
response.

(1) [ These services shall be limited annually to 26
weeks. ] Service authorization shall be required for Medicaid
reimbursement prior to the onset of services. Services rendered before the date
of authorization shall not be reimbursed.

[ (2) Service authorization shall be required for
services to continue beyond the initial 26 weeks.

(3)(2) ] Service-specific provider intakes
shall be required at the onset of services and ISPs shall be required during
the entire duration of services. Services based upon incomplete, missing, or
outdated service-specific provider intakes or ISPs shall be denied
reimbursement. Requirements for service-specific provider intakes and ISPs are
set out in this section.

[ (4)(3) ] These services may only be
rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a
QMHP-E.

c. Therapeutic day treatment (TDT) shall be provided two or
more hours per day in order to provide therapeutic interventions. Day treatment
programs [ , limited annually to 780 units, ] provide
evaluation; medication education and management; opportunities to learn and use
daily living skills and to enhance social and interpersonal skills (e.g.,
problem solving, anger management, community responsibility, increased impulse
control, and appropriate peer relations, etc.); and individual, group and
family counseling.

(1) Service authorization shall be required for Medicaid
reimbursement.

(2) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
service-specific provider intakes and ISPs are set out in this section.

(3) These services may be rendered only by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a QMHP-E.

d. Community-based services for children and adolescents
[ underyounger than ] 21 years of age (Level A)
pursuant to 42 CFR 440.031(d).

(1) Such services shall be a combination of therapeutic
services rendered in a residential setting. The residential services will
provide structure for daily activities, psychoeducation, therapeutic
supervision, care coordination, and psychiatric treatment to ensure the
attainment of therapeutic mental health goals as identified in the individual
service plan (plan of care). Individuals qualifying for this service must
demonstrate medical necessity for the service arising from a condition due to
mental, behavioral or emotional illness that results in significant functional
impairments in major life activities in the home, school, at work, or in the
community. The service must reasonably be expected to improve the child's
condition or prevent regression so that the services will no longer be needed.
The application of a national standardized set of medical necessity criteria in
use in the industry, such as McKesson InterQual® Criteria or an
equivalent standard authorized in advance by DMAS, shall be required for this
service.

(2) In addition to the residential services, the child must
receive, at least weekly, individual psychotherapy that is provided by an LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP.

(3) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.

(4) Authorization shall be required for Medicaid
reimbursement. Services that were rendered before the date of service
authorization shall not be reimbursed.

(5) Room and board costs shall not be reimbursed. DMAS shall
reimburse only for services provided in facilities or programs with no more
than 16 beds.

(6) These residential providers must be licensed by the
Department of Social Services, Department of Juvenile Justice, or Department of
Behavioral Health and Developmental Services under the Standards for Licensed
Children's Residential Facilities (22VAC40-151), Regulation Governing Juvenile
Group Homes and Halfway Houses (6VAC35-41), or Regulations for Children's
Residential Facilities (12VAC35-46).

(7) Daily progress notes shall document a minimum of seven
psychoeducational activities per week. Psychoeducational programming must
include [ , but is not limited to, ] development or
maintenance of daily living skills, anger management, social skills, family
living skills, communication skills, stress management, and any care
coordination activities.

(8) The facility/group home must coordinate services with
other providers. Such care coordination shall be documented in the individual's
medical record. The documentation shall include who was contacted, when the
contact occurred, and what information was transmitted.

(9) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
intakes and ISPs are set out in 12VAC30-60-61.

(10) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.

(1) Such services must be therapeutic services rendered in a
residential setting. The residential services will provide structure for daily
activities, psychoeducation, therapeutic supervision, care coordination, and
psychiatric treatment to ensure the attainment of therapeutic mental health
goals as identified in the individual service plan (plan of care). Individuals
qualifying for this service must demonstrate medical necessity for the service
arising from a condition due to mental, behavioral or emotional illness that
results in significant functional impairments in major life activities in the
home, school, at work, or in the community. The service must reasonably be
expected to improve the child's condition or prevent regression so that the
services will no longer be needed. The application of a national standardized
set of medical necessity criteria in use in the industry, such as McKesson
InterQual® Criteria, or an equivalent standard authorized in advance
by DMAS shall be required for this service.

(2) Authorization is required for Medicaid reimbursement.
Services that are rendered before the date of service authorization shall not
be reimbursed.

(3) Room and board costs shall not be reimbursed. Facilities
that only provide independent living services are not reimbursed. DMAS shall
reimburse only for services provided in facilities or programs with no more
than 16 beds.

(4) These residential providers must be licensed by the
Department of Behavioral Health and Developmental Services (DBHDS) under the
Regulations for Children's Residential Facilities (12VAC35-46).

(5) Daily progress notes shall document that a minimum of
seven psychoeducational activities per week occurs. Psychoeducational
programming must include [ , but is not limited to, ]
development or maintenance of daily living skills, anger management, social
skills, family living skills, communication skills, and stress management. This
service may be provided in a program setting or a community-based group home.

(6) The individual must receive, at least weekly, individual
psychotherapy and, at least weekly, group psychotherapy that is provided as
part of the program.

(7) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.

(8) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services that are based upon incomplete, missing, or outdated
service-specific provider intakes or ISPs shall be denied reimbursement.
Requirements for intakes and ISPs are set out in 12VAC30-60-61.

(9) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.

(10) The facility/group home shall coordinate necessary
services with other providers. Documentation of this care coordination shall be
maintained by the facility/group home in the individual's record. The
documentation shall include who was contacted, when the contact occurred, and
what information was transmitted.

f. Mental health family support partners.

(1) Mental health family support partners are peer recovery
support services and are nonclinical, peer-to-peer activities that engage,
educate, and support the caregiver and an individual's self-help efforts to
improve health recovery resiliency and wellness. Mental health family support partners
is a peer support service and is a strength-based, individualized service
provided to the caregiver of a Medicaid-eligible individual younger than 21
years of age with a mental health disorder that is the focus of support. The
services provided to the caregiver and individual must be directed exclusively
toward the benefit of the Medicaid-eligible individual. Services are expected
to improve outcomes for individuals younger than 21 years of age with complex
needs who are involved with multiple systems and increase the individual's and
family's confidence and capacity to manage their own services and supports
while promoting recovery and healthy relationships. These services are rendered
by a PRS who is (i) a parent of a minor or adult child with a similar mental
health disorder or (ii) an adult with personal experience with a family member
with a similar mental health disorder with experience navigating behavioral
health care services. The PRS shall perform the service within the scope of his
knowledge, lived experience, and education.

(2) Under the clinical oversight of the LMHP making the
recommendation for mental health family support partners, the peer recovery
specialist in consultation with his direct supervisor shall develop a recovery,
resiliency, and wellness plan based on the LMHP's recommendation for service,
the individual's and the caregiver's perceived recovery needs, and any clinical
assessments or service specific provider intakes as defined in this section
within 30 calendar days of the initiation of service. Development of the
recovery, resiliency, and wellness plan shall include collaboration with the
individual and the individual's caregiver. Individualized goals and strategies
shall be focused on the individual's identified needs for self-advocacy and
recovery. The recovery, resiliency, and wellness plan shall also include
documentation of how many days per week and how many hours per week are
required to carry out the services in order to meet the goals of the plan. The
recovery, resiliency, and wellness plan shall be completed, signed, and dated
by the LMHP, the PRS, the direct supervisor, the individual, and the
individual's caregiver within 30 calendar days of the initiation of service.
The PRS shall act as an advocate for the individual, encouraging the individual
and the caregiver to take a proactive role in developing and updating goals and
objectives in the individualized recovery planning.

(3) Documentation of required activities shall be required as
set forth in 12VAC30-130-5200 A and C through J.

(4) Limitations and exclusions to service delivery shall be
the same as set forth in 12VAC30-130-5210.

(5) Caregivers of individuals younger than 21 years of age who
qualify to receive mental health family support partners (i) care for an
individual with a mental health disorder who requires recovery assistance and
(ii) meet two or more of the following:

(a) Individual and his caregiver need peer-based
recovery-oriented services for the maintenance of wellness and the acquisition
of skills needed to support the individual.

(b) Individual and his caregiver need assistance to develop
self-advocacy skills to assist the individual in achieving self-management of
the individual's health status.

(c) Individual and his caregiver need assistance and support
to prepare the individual for a successful work or school experience.

(d) Individual and his caregiver need assistance to help the
individual and caregiver assume responsibility for recovery.

(6) Individuals 18 through 20 years of age who meet the
medical necessity criteria in 12VAC30-50-226 B 7 e, who would benefit from
receiving peer supports directly and who choose to receive mental health peer
support services directly instead of through their caregiver, shall be
permitted to receive mental health peer support services by an appropriate PRS.

(7) To qualify for continued mental health family support
partners, the requirements for continued services set forth in 12VAC30-130-5180
D shall be met.

(8) Discharge criteria from mental health family support
partners shall be the same as set forth in 12VAC30-130-5180 E.

(9) Mental health family support partners services shall be
rendered on an individual basis or in a group.

(10) Prior to service initiation, a documented recommendation
for mental health family support partners services shall be made by a licensed
mental health professional (LMHP) who is acting within his scope of practice
under state law. The recommendation shall verify that the individual meets the
medical necessity criteria set forth in subdivision 5 [ a (5) ]
of this subsection. The recommendation shall be valid for no longer than 30
calendar days.

(11) Effective July 1, 2017, a peer recovery specialist shall
have the qualifications, education, experience, and certification required by
DBHDS in order to be eligible to register with the Virginia Board of Counseling
on or after July 1, 2018. Upon the promulgation of regulations by the Board of
Counseling, registration of peer recovery specialists by the Board of
Counseling shall be required. The PRS shall perform mental health family
support partners services under the oversight of the LMHP making the
recommendation for services and providing the clinical oversight of the
recovery, resiliency, and wellness plan.

(12) The PRS shall be employed by or have a contractual
relationship with the enrolled provider licensed for one of the following:

(a) Acute care general and emergency department hospital
services licensed by the Department of Health.

(g) A community mental health and rehabilitative services
provider licensed by the Department of Behavioral Health and Developmental
Services as a provider of one of the following community mental health and
rehabilitative services as defined in this section, 12VAC30-50-226,
12VAC30-50-420, or 12VAC30-50-430 for which the individual younger than 21
years meets medical necessity criteria (i) intensive in home; (ii)
therapeutic day treatment; (iii) day treatment or partial hospitalization;
(iv) crisis intervention; (v) crisis stabilization; (vi) mental health skill
building; or (vii) mental health case management.

(13) Only the licensed and enrolled provider as referenced in
subdivision 5 f (12) of this subsection shall be eligible to bill and receive
reimbursement from DMAS or its contractor for mental health family support
partner services. Payments shall not be permitted to providers that fail to
enter into an enrollment agreement with DMAS or its contractor. Reimbursement
shall be subject to retraction for any billed service that is determined not to
be in compliance with DMAS requirements.

(14) Supervision of the PRS shall be required as set forth in
12VAC30-130-5190 E and 12VAC30-130-5200 G.

6. Inpatient psychiatric services shall be covered for
individuals younger than age 21 for medically necessary stays in inpatient
psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2) for the
purpose of diagnosis and treatment of mental health and behavioral disorders
identified under EPSDT when such services are rendered by (i) a psychiatric
hospital or an inpatient psychiatric program in a hospital accredited by the
Joint Commission on Accreditation of Healthcare Organizations; or (ii) a
psychiatric facility that is accredited by the Joint Commission on Accreditation
of Healthcare Organizations or the Commission on Accreditation of
Rehabilitation Facilities. Inpatient psychiatric hospital admissions at general
acute care hospitals and freestanding psychiatric hospitals shall also be
subject to the requirements of 12VAC30-50-100, 12VAC30-50-105, and
12VAC30-60-25. Inpatient psychiatric admissions to residential treatment
facilities shall also be subject to the requirements of Part XIV
(12VAC30-130-850 et seq.) of Amount, Duration and Scope of Selected Services.

a. The inpatient psychiatric services benefit for individuals
younger than 21 years of age shall include services defined at 42 CFR 440.160
that are provided under the direction of a physician pursuant to a
certification of medical necessity and plan of care developed by an
interdisciplinary team of professionals and shall involve active treatment
designed to achieve the child's discharge from inpatient status at the earliest
possible time. The inpatient psychiatric services benefit shall include
services provided under arrangement furnished by Medicaid enrolled providers
other than the inpatient psychiatric facility, as long as the inpatient
psychiatric facility (i) arranges for and oversees the provision of all
services, (ii) maintains all medical records of care furnished to the
individual, and (iii) ensures that the services are furnished under the
direction of a physician. Services provided under arrangement shall be
documented by a written referral from the inpatient psychiatric facility. For
purposes of pharmacy services, a prescription ordered by an employee or
contractor of the facility who is licensed to prescribe drugs shall be
considered the referral.

b. Eligible services provided under arrangement with the
inpatient psychiatric facility shall vary by provider type as described in this
subsection. For purposes of this section, emergency services means the same as
is set out in 12VAC30-50-310 B.

c. Inpatient psychiatric services are reimbursable only when
the treatment program is fully in compliance with (i) 42 CFR Part 441 Subpart
D, specifically 42 CFR 441.151(a) and (b) and [ 42 CFR ]
441.152 through [ 42 CFR ] 441.156, and (ii) the conditions of
participation in 42 CFR Part 483 Subpart G. Each admission must be
preauthorized and the treatment must meet DMAS requirements for clinical
necessity.

d. Service limits may be exceeded based on medical necessity
for individuals eligible for EPSDT.

7. Hearing aids shall be reimbursed for individuals younger
than 21 years of age according to medical necessity when provided by
practitioners licensed to engage in the practice of fitting or dealing in
hearing aids under the Code of Virginia.

9. Services facilitators shall be required for all consumer-directed
personal care services consistent with the requirements set out in
12VAC30-120-935.

10. Behavioral therapy services shall be covered for
individuals [ under the age of younger than ]
21 years [ of age ].

a. Definitions. The following words and terms when used in
this subsection shall have the following meanings unless the context clearly
indicates otherwise:

"Behavioral therapy" means systematic
interventions provided by licensed practitioners acting within the scope of
practice defined under a Virginia [ Department of ] Health
Professions [ Regulatory Board regulatory board ]
and covered as remedial care under 42 CFR 440.130(d) [ within
the home ] to individuals [ under
younger than ] 21 years of age. Behavioral therapy includes applied
behavioral analysis [ and is primarily provided in the family
home ]. Family [ counseling and ] training
related to the implementation of the behavioral therapy shall be included as
part of the behavioral therapy service. Behavioral therapy services shall be subject
to clinical reviews and determined as medically necessary. Behavioral therapy
may be [ intermittently ] provided in
[ the individual's home and ] community settings
[ when approved settings are as ] deemed by
DMAS or its contractor as medically necessary treatment.

[ "Counseling" means a professional mental
health service that can only be provided by a person holding a license issued
by a health regulatory board at the Department of Health Professions, which
includes conducting assessments, making diagnoses of mental disorders and
conditions, establishing treatment plans, and determining treatment
interventions. ]

"Individual" means the child or adolescent
[ under the age of younger than ] 21
[ years of age ] who is receiving behavioral therapy services.

"Primary care provider" means a licensed medical
practitioner who provides preventive and primary health care and is responsible
for providing routine EPSDT screening and referral and coordination of other
medical services needed by the individual.

b. Behavioral therapy services shall be designed to enhance
communication skills and decrease maladaptive patterns of behavior, which if
left untreated, could lead to more complex problems and the need for a greater
or a more intensive level of care. The service goal shall be to ensure the
individual's family or caregiver is trained to effectively manage the
individual's behavior in the home using modification strategies. [ The
All ] services shall be provided in accordance with the [ individual
service plan ISP ] and clinical assessment summary.

c. Behavioral therapy services shall be covered when
recommended by the individual's primary care provider or other licensed
physician, licensed physician assistant, or licensed nurse practitioner and
determined by DMAS or its contractor to be medically necessary to correct or
ameliorate significant impairments in major life activities that have resulted
from either developmental, behavioral, or mental disabilities. Criteria for
medical necessity are set out in 12VAC30-60-61 H. Service-specific provider
intakes shall be required at the onset of these services in order to receive
authorization for reimbursement. Individual service plans (ISPs) shall be
required throughout the entire duration of services. The services shall be
provided in accordance with the individual service plan and clinical assessment
summary. These services shall be provided in settings that are natural or
normal for a child or adolescent without a disability, such as [ his
the individual's ] home, unless there is justification in the ISP,
which has been authorized for reimbursement, to include service settings that
promote a generalization of behaviors across different settings to maintain the
targeted functioning outside of the treatment setting in the [ patient's
residence individual's home ] and the larger community
within which the individual resides. Covered behavioral therapy services shall
include:

2. School divisions may provide routine well-child screening
services under the State Plan. Diagnostic and treatment services that are
otherwise covered under early and periodic screening, diagnosis and treatment
services [ , ] shall not be covered for school divisions.
School divisions to receive reimbursement for the screenings shall be enrolled
with DMAS as clinic providers.

a. Children enrolled in managed care organizations shall
receive screenings from those organizations. School divisions shall not receive
reimbursement for screenings from DMAS for these children.

b. School-based services are listed in a recipient's
individualized education program (IEP) and covered under one or more of the
service categories described in § 1905(a) of the Social Security Act.
These services are necessary to correct or ameliorate defects of physical or
mental illnesses or conditions.

3. Service providersProviders shall be licensed
under the applicable state practice act or comparable licensing criteria by the
Virginia Department of Education [ , ] and shall meet
applicable qualifications under 42 CFR Part 440. Identification of defects,
illnesses or conditions and services necessary to correct or ameliorate them
shall be performed by practitioners qualified to make those determinations
within their licensed scope of practice, either as a member of the IEP team or
by a qualified practitioner outside the IEP team.

a. Service providersProviders shall be employed
by the school division or under contract to the school division.

b. Supervision of services by providers recognized in
subdivision 4 of this subsection shall occur as allowed under federal
regulations and consistent with Virginia law, regulations, and DMAS provider
manuals.

c. The services described in subdivision 4 of this subsection
shall be delivered by school providers, but may also be available in the
community from other providers.

d. Services in this subsection are subject to utilization
control as provided under 42 CFR Parts 455 and 456.

e. The IEP shall determine whether or not the services
described in subdivision 4 of this subsection are medically necessary and that
the treatment prescribed is in accordance with standards of medical practice.
Medical necessity is defined as services ordered by IEP providers. The IEP
providers are qualified Medicaid providers to make the medical necessity
determination in accordance with their scope of practice. The services must be
described as to the amount, duration and scope.

4. Covered services include:

a. Physical therapy, occupational therapy and services for
individuals with speech, hearing, and language disorders, performed by, or
under the direction of, providers who meet the qualifications set forth at 42
CFR 440.110. This coverage includes audiology services.

b. Skilled nursing services are covered under 42 CFR 440.60.
These services are to be rendered in accordance to the licensing standards and
criteria of the Virginia Board of Nursing. Nursing services are to be provided
by licensed registered nurses or licensed practical nurses but may be delegated
by licensed registered nurses in accordance with the regulations of the Virginia
Board of Nursing, especially the section on delegation of nursing tasks and
procedures. The licensed practical nurse is under the supervision of a
registered nurse.

(1) The coverage of skilled nursing services shall be of a
level of complexity and sophistication (based on assessment, planning,
implementation and evaluation) that is consistent with skilled nursing services
when performed by a licensed registered nurse or a licensed practical nurse.
These skilled nursing services shall include [ , but not necessarily be
limited to ] dressing changes, maintaining patent airways, medication
administration/monitoring and urinary catheterizations.

(2) Skilled nursing services shall be directly and
specifically related to an active, written plan of care developed by a
registered nurse that is based on a written order from a physician, physician
assistant or nurse practitioner for skilled nursing services. This order shall
be recertified on an annual basis.

c. Psychiatric and psychological services performed by
licensed practitioners within the scope of practice are defined under state law
or regulations and covered as physicians' services under 42 CFR 440.50 or
medical or other remedial care under 42 CFR 440.60. These outpatient services
include individual medical psychotherapy, group medical psychotherapy coverage,
and family medical psychotherapy. Psychological and neuropsychological testing
are allowed when done for purposes other than educational diagnosis, school
admission, evaluation of an individual with intellectual disability prior to
admission to a nursing facility, or any placement issue. These services are
covered in the nonschool settings also. School providers who may render these
services when licensed by the state include psychiatrists, licensed clinical
psychologists, school psychologists, licensed clinical social workers,
professional counselors, psychiatric clinical nurse specialists, marriage and
family therapists, and school social workers.

d. Personal care services are covered under 42 CFR 440.167 and
performed by persons qualified under this subsection. The personal care
assistant is supervised by a DMAS recognized school-based health professional
who is acting within the scope of licensure. This practitioner develops a
written plan for meeting the needs of the child, which is implemented by the
assistant. The assistant must have qualifications comparable to those for other
personal care aides recognized by the Virginia Department of Medical Assistance
Services. The assistant performs services such as assisting with toileting,
ambulation, and eating. The assistant may serve as an aide on a specially
adapted school vehicle that enables transportation to or from the school or
school contracted provider on days when the student is receiving a
Medicaid-covered service under the IEP. Children requiring an aide during
transportation on a specially adapted vehicle shall have this stated in the
IEP.

e. Medical evaluation services are covered as physicians'
services under 42 CFR 440.50 or as medical or other remedial care under 42 CFR
440.60. Persons performing these services shall be licensed physicians,
physician assistants, or nurse practitioners. These practitioners shall
identify the nature or extent of a child's medical or other health related condition.

f. Transportation is covered as allowed under 42 CFR 431.53
and described at State Plan Attachment 3.1-D (12VAC30-50-530). Transportation
shall be rendered only by school division personnel or contractors.
Transportation is covered for a child who requires transportation on a
specially adapted school vehicle that enables transportation to or from the
school or school contracted provider on days when the student is receiving a
Medicaid-covered service under the IEP. Transportation shall be listed in the
child's IEP. Children requiring an aide during transportation on a specially
adapted vehicle shall have this stated in the IEP.

g. Assessments are covered as necessary to assess or reassess
the need for medical services in a child's IEP and shall be performed by any of
the above licensed practitioners within the scope of practice. Assessments and
reassessments not tied to medical needs of the child shall not be covered.

5. DMAS will ensure through quality management review that
duplication of services will be monitored. School divisions have a
responsibility to ensure that if a child is receiving additional therapy
outside of the school, that there will be coordination of services to avoid
duplication of service.

D. Family planning services and supplies for individuals of
child-bearing age.

1. Service must be ordered or prescribed and directed or
performed within the scope of the license of a practitioner of the healing arts.

2. Family planning services shall be defined as those services
that delay or prevent pregnancy. Coverage of such services shall not include
services to treat infertility or services to promote fertility. Family planning
services shall not cover payment for abortion services and no funds shall be
used to perform, assist, encourage, or make direct referrals for abortions.

3. Family planning services as established by
§ 1905(a)(4)(C) of the Social Security Act include annual family planning
exams; cervical cancer screening for women; sexually transmitted infection
(STI) testing; lab services for family planning and STI testing; family
planning education, counseling, and preconception health; sterilization
procedures; nonemergency transportation to a family planning service; and U.S.
Food and Drug Administration approved prescription and over-the-counter
contraceptives, subject to limits in 12VAC30-50-210.

12VAC30-60-61. Services related to the Early and Periodic
Screening, Diagnosis and Treatment Program (EPSDT); community mental health
[ and behavioral therapy ] services for children [ ;
behavioral therapy services for children ].

A. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context indicates
otherwise:

"At risk" means one or more of the following: (i)
within the two weeks before the intake, the individual shall be screened by an
LMHP for escalating behaviors that have put either the individual or others at
immediate risk of physical injury; (ii) the parent/guardian is unable to manage
the individual's mental, behavioral, or emotional problems in the home and is
actively, within the past two to four weeks, seeking an out-of-home placement;
(iii) a representative of either a juvenile justice agency, a department of
social services (either the state agency or local agency), a community services
board/behavioral health authority, the Department of Education, or an LMHP, as
defined in 12VAC35-105-20, and who is neither an employee of nor consultant to
the intensive in-home (IIH) services or therapeutic day treatment (TDT)
provider, has recommended an out-of-home placement absent an immediate change
of behaviors and when unsuccessful mental health services are evident; (iv) the
individual has a history of unsuccessful services (either crisis intervention,
crisis stabilization, outpatient psychotherapy, outpatient substance abuse
services, or mental health support) within the past 30 days; (v) the treatment
team or family assessment planning team (FAPT) recommends IIH services or TDT
for an individual currently who is either: (a) transitioning out of residential
treatment facility Level C services, (b) transitioning out of a group home
Level A or B services, (c) transitioning out of acute psychiatric
hospitalization, or (d) transitioning between foster homes, mental health case
management, crisis intervention, crisis stabilization, outpatient
psychotherapy, or outpatient substance abuse services.

"Failed services" or "unsuccessful
services" means, as measured by ongoing behavioral, mental, or physical
distress, that the [ service or ] services did not treat or
resolve the individual's mental health or behavioral issues.

"Individual" means the Medicaid-eligible person
receiving these services and for the purpose of this section includes children
from birth up to 12 years of age or adolescents ages 12 through 20 years.

"Licensed assistant behavior analyst" means a
person who has met the licensing requirements of 18VAC85-150 and holds a valid
license issued by the Department of Health Professions.

"Licensed behavior analyst" means a person who
has met the licensing requirements of 18VAC85-150 and holds a valid license
issued by the Department of Health Professions.

"New service" means a community mental health
rehabilitation service for which the individual does not have a current service
authorization in effect as of July 17, 2011.

"Out-of-home placement" means placement in one or
more of the following: (i) either a Level A or Level B group home; (ii) regular
foster home if the individual is currently residing with his biological family
and, due to his behavior problems, is at risk of being placed in the custody of
the local department of social services; (iii) treatment foster care if the
individual is currently residing with his biological family or a regular foster
care family and, due to the individual's behavioral problems, is at risk of
removal to a higher level of care; (iv) Level C residential facility; (v)
emergency shelter for the individual only due either to his mental health or
behavior or both; (vi) psychiatric hospitalization; or (vii) juvenile justice
system or incarceration.

"Service-specific provider intake" means the
evaluation that is conducted according to the Department of Medical Assistance
Services (DMAS) intake definition set out in 12VAC30-50-130.

B. Utilization review requirements for all services in
this section.

1. The services described in this section shall be
rendered consistent with the definitions, service limits, and requirements
described in this section and in 12VAC30-50-130.

2. Providers shall be required to refund payments made by
Medicaid if they fail to maintain adequate documentation to support billed
activities.

3. Individual service plans (ISPs) shall meet all of the
requirements set forth in 12VAC30-60-143 B 7.

C. IntensiveUtilization review of intensive
in-home (IIH) services for children and adolescents.

1. The service definition for intensive in-home (IIH) services
is contained in 12VAC30-50-130.

2. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from mental, behavioral or emotional
illness [ whichthat ] results in significant
functional impairments in major life activities. Individuals must meet at least
two of the following criteria on a continuing or intermittent basis to be
authorized for these services:

a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.

b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services or judicial system
are or have been necessary.

c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.

3. Prior to admission, an appropriate service-specific
provider intake, as defined in 12VAC30-50-130, shall be conducted by the
licensed mental health professional (LMHP), LMHP-supervisee, LMHP-resident, or
LMHP-RP, documenting the individual's diagnosis and describing how service
needs can best be met through intervention provided typically but not solely in
the individual's residence. The service-specific provider intake shall describe
how the individual's clinical needs put the individual at risk of out-of-home
placement and shall be conducted face-to-face in the individual's residence.
Claims for services that are based upon service-specific provider intakes that
are incomplete, outdated (more than 12 months old), or missing shall not be
reimbursed.

4. An individual service plan (ISP) shall be fully completed,
signed, and dated by either an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a
QMHP-C, or a QMHP-E and the individual and individual's parent/guardian within
30 days of initiation of services. The ISP shall meet all of the requirements
as defined in 12VAC30-50-226.

5. DMAS shall not reimburse for dates of services in which the
progress notes are not individualized and child-specific. Duplicated progress
notes shall not constitute the required child-specific individualized progress
notes. Each progress note shall demonstrate unique differences particular to
the individual's circumstances, treatment, and progress. Claim payments shall
be retracted for services that are supported by documentation that does not
demonstrate unique differences particular to the individual.

6. Services shall be directed toward the treatment of the
eligible individual and delivered primarily in the family's residence with the
individual present. As clinically indicated, the services may be rendered in
the community if there is documentation, on that date of service, of the
necessity of providing services in the community. The documentation shall
describe how the alternative community service location supports the identified
clinical needs of the individual and describe how it facilitates the implementation
of the ISP. For services provided outside of the home, there shall be
documentation reflecting therapeutic treatment as set forth in the ISP provided
for that date of service in the appropriately signed and dated progress notes.

7. These services shall be provided when the clinical needs of
the individual put him at risk for out-of-home placement, as these terms are
defined in this section:

a. When services that are far more intensive than outpatient
clinic care are required to stabilize the individual in the family situation,
or

b. When the individual's residence as the setting for services
is more likely to be successful than a clinic.

The service-specific provider intake shall describe how the
individual meets either subdivision a or b of this subdivision [ 7 ].

8. Services shall not be provided if the individual is no
longer a resident of the home.

9. Services shall also be used to facilitate the transition to
home from an out-of-home placement when services more intensive than outpatient
clinic care are required for the transition to be successful. The individual
and responsible parent/guardian shall be available and in agreement to
participate in the transition.

10. At least one parent/legal guardian or responsible adult
with whom the individual is living must be willing to participate in the
intensive in-home services with the goal of keeping the individual with the
family. In the instance of this service, a responsible adult shall be an adult
who lives in the same household with the child and is responsible for engaging
in therapy and service-related activities to benefit the individual.

11. The enrolled service provider shall be licensed by
the Department of Behavioral Health and Developmental Services (DBHDS) as a
provider of intensive in-home services. The provider shall also have a provider
enrollment agreement with DMAS or its contractor in effect prior to the
delivery of this service that indicates that the provider will offer intensive
in-home services.

12. Services must only be provided by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-C, or QMHP-E. Reimbursement shall
not be provided for such services when they have been rendered by a QPPMH as
defined in 12VAC35-105-20.

13. The billing unit for intensive in-home service shall be
one hour. Although the pattern of service delivery may vary, intensive in-home
services is an intensive service provided to individuals for whom there is an
ISP in effect which demonstrates the need for a minimum of three hours a week
of intensive in-home service, and includes a plan for service provision of a
minimum of three hours of service delivery per individual/family per week in
the initial phase of treatment. It is expected that the pattern of service
provision may show more intensive services and more frequent contact with the
individual and family initially with a lessening or tapering off of intensity
toward the latter weeks of service. Service plans shall incorporate an
individualized discharge plan that describes transition from intensive in-home
to less intensive or nonhome based services.

14. The ISP, as defined in 12VAC30-50-226, shall be updated as
the individual's needs and progress changes and signed by either the parent or
legal guardian and the individual. Documentation shall be provided if the
individual, who is a minor child, is unable or unwilling to sign the ISP. If
there is a lapse in services that is greater than 31 consecutive calendar days
without any communications from family members/legal guardian or the individual
with the service provider, the provider shall discharge the individual.
If the individual continues to need services, then a new intake/admission shall
be documented and a new service authorization shall be required.

15. The provider shall ensure that the maximum
staff-to-caseload ratio fully meets the needs of the individual.

16. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the service
provider shall contact the case manager and provide notification of the
provision of services. In addition, the provider shall send monthly updates to
the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 days of the service discontinuation date. Service
providersProviders and case managers who are using the same
electronic health record for the individual shall meet requirements for
delivery of the notification, monthly updates, and discharge summary upon entry
of the information in the electronic health records.

17. Emergency assistance shall be available 24 hours per day,
seven days a week.

19. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or guardian, shall
inform him of the individual's receipt of IIH services. The documentation shall
include who was contacted, when the contact occurred, and what information was
transmitted.

D. TherapeuticUtilization review of therapeutic
day treatment for children and adolescents.

1. The service definition for therapeutic day treatment (TDT)
for children and adolescents is contained in 12VAC30-50-130.

2. Therapeutic day treatment is appropriate for children and
adolescents who meet one of the following:

a. Children and adolescents who require year-round treatment in
order to sustain behavior or emotional gains.

b. Children and adolescents whose behavior and emotional
problems are so severe they cannot be handled in self-contained or resource
emotionally disturbed (ED) classrooms without:

(1) This programming during the school day; or

(2) This programming to supplement the school day or school
year.

c. Children and adolescents who would otherwise be placed on
homebound instruction because of severe emotional/behavior problems that
interfere with learning.

d. Children and adolescents who (i) have deficits in social
skills, peer relations or dealing with authority; (ii) are hyperactive; (iii)
have poor impulse control; (iv) are extremely depressed or marginally connected
with reality.

e. Children in preschool enrichment and early intervention
programs when the children's emotional/behavioral problems are so severe that
they cannot function in these programs without additional services.

3. The service-specific provider intake shall document the
individual's behavior and describe how the individual meets these specific
service criteria in subdivision 2 of this subsection.

4. Prior to admission to this service, a service-specific
provider intake shall be conducted by the LMHP as defined in 12VAC35-105-20.

5. An ISP shall be fully completed, signed, and dated by an
LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or QMHP-E and by the
individual or the parent/guardian within 30 days of initiation of services and
shall meet all requirements of an ISP as defined in 12VAC30-50-226. Individual
progress notes shall be required for each contact with the individual and shall
meet all of the requirements as defined in 12VAC30-50-130.

6. Such services shall not duplicate those services provided
by the school.

7. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from a condition due to mental,
behavioral or emotional illness [ whichthat ] results
in significant functional impairments in major life activities. Individuals
shall meet at least two of the following criteria on a continuing or
intermittent basis:

a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.

b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services, or judicial
system are or have been necessary.

c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.

8. The enrolled provider of therapeutic day treatment for child
and adolescent services shall be licensed by DBHDS to provide day support
services. The provider shall also have a provider enrollment agreement in
effect with DMAS prior to the delivery of this service that indicates that the
provider offers therapeutic day treatment services for children and
adolescents.

10. The minimum staff-to-individual ratio as defined by DBHDS
licensing requirements shall ensure that adequate staff is available to meet
the needs of the individual identified on the ISP.

11. The program shall operate a minimum of two hours per day
and may offer flexible program hours (i.e., before or after school or during
the summer). One unit of service shall be defined as a minimum of two hours but
less than three hours in a given day. Two units of service shall be defined as
a minimum of three but less than five hours in a given day. Three units of
service shall be defined as five or more hours of service in a given day.

12. Time required for academic instruction when no treatment
activity is going on shall not be included in the billing unit.

13. Services shall be provided following a service-specific
provider intake that is conducted by an LMHP, LMHP-supervisee, LMHP-resident,
or LMHP-RP. An LMHP, LMHP-supervisee, or LMHP-resident shall make and document
the diagnosis. The service-specific provider intake shall include the elements
as defined in 12VAC30-50-130.

14. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the provider
shall collaborate with the case manager and provide notification of the
provision of services. In addition, the provider shall send monthly updates to
the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 days of the service discontinuation date. Service
providersProviders and case managers using the same electronic
health record for the individual shall meet requirements for delivery of the
notification, monthly updates, and discharge summary upon entry of this
documentation into the electronic health record.

15. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
guardian, shall inform [ himthe primary care provider ]
of the child's receipt of community mental health rehabilitative services. The
documentation shall include who was contacted, when the contact occurred, and
what information was transmitted. The parent/legal guardian shall be required
to give written consent that this provider has permission to inform the primary
care provider of the child's or adolescent's receipt of community mental health
rehabilitative services.

16. Providers shall comply with DMAS marketing requirements as
set out in 12VAC30-130-2000. Providers that DMAS determines have violated these
marketing requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.

17. If there is a lapse in services greater than 31
consecutive calendar days, the provider shall discharge the individual. If the
individual continues to need services, a new intake/admission documentation
shall be prepared and a new service authorization shall be required.

E. Community-basedUtilization review of
community-based services for children and adolescents [ underyounger
than ] 21 years of age (Level A).

1. The staff ratio must be at least [ 1one ]
to [ 6six ] during the day and at least [ 1one ] to 10 between 11 p.m. and 7 a.m. The program director
supervising the program/group home must be, at minimum, a QMHP-C or QMHP-E (as
defined in 12VAC35-105-20). The program director must be employed full time.

2. In order for Medicaid reimbursement to be approved, at
least 50% of the provider's direct care staff at the group home must meet DBHDS
paraprofessional staff criteria, defined in 12VAC35-105-20.

3. Authorization is required for Medicaid reimbursement. All
community-based services for children and adolescents [ underyounger
than ] 21 (Level A) require authorization prior to reimbursement for
these services. Reimbursement shall not be made for this service when other
less intensive services may achieve stabilization.

4. Services must be provided in accordance with an individual
service plan (ISP), which must be fully completed within 30 days of
authorization for Medicaid reimbursement.

5. Prior to admission, a service-specific provider intake
shall be conducted according to DMAS specifications described in
12VAC30-50-130.

6. Such service-specific provider intakes shall be performed
by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.

7. If an individual receiving community-based services for
children and adolescents [ underyounger than ] 21
[ years of age ] (Level A) is also receiving case management
services, the provider shall collaborate with the case manager by notifying the
case manager of the provision of Level A services and shall send monthly
updates on the individual's progress. When the individual is discharged from
Level A services, a discharge summary shall be sent to the case manager within
30 days of the service discontinuation date. Service providersProviders
and case managers who are using the same electronic health record for the
individual shall meet requirements for the delivery of the notification,
monthly updates, and discharge summary upon entry of this documentation into
the electronic health record.

F. TherapeuticUtilization review of therapeutic
behavioral services for children and adolescents [ underyounger
than ] 21 years of age (Level B).

1. The staff ratio must be at least [ 1one ]
to [ 4four ] during the day and at least [ 1one ] to [ 8eight ] between 11 p.m. and 7
a.m. The clinical director must be a licensed mental health professional. The
caseload of the clinical director must not exceed 16 individuals including all
sites for which the same clinical director is responsible.

2. The program director must be full time and be a QMHP-C or
QMHP-E with a bachelor's degree and at least one year's clinical experience.

3. For Medicaid reimbursement to be approved, at least 50% of
the provider's direct care staff at the group home shall meet DBHDS
paraprofessional staff criteria, as defined in 12VAC35-105-20. The
program/group home must coordinate services with other providers.

4. All therapeutic behavioral services (Level B) shall be
authorized prior to reimbursement for these services. Services rendered without
such prior authorization shall not be covered.

5. Services must be provided in accordance with an ISP, which
shall be fully completed within 30 days of authorization for Medicaid
reimbursement.

6. Prior to admission, a service-specific provider intake
shall be performed using all elements specified by DMAS in 12VAC30-50-130.

7. Such service-specific provider intakes shall be performed
by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.

8. If an individual receiving therapeutic behavioral services
for children and adolescents [ underyounger than ] 21
[ years of age ] (Level B) is also receiving case management
services, the therapeutic behavioral services provider must collaborate with
the care coordinator/case manager by notifying him of the provision of Level B
services and the Level B services provider shall send monthly updates on the
individual's treatment status. When the individual is discharged from Level B
services, a discharge summary shall be sent to the care coordinator/case
manager within 30 days of the discontinuation date.

9. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
guardian, shall inform [ himthe primary care provider ]
of the individual's receipt of these Level B services. The documentation shall
include who was contacted, when the contact occurred, and what information was
transmitted. If these individuals are children or adolescents, then the
parent/legal guardian shall be required to give written consent that this
provider has permission to inform the primary care provider of the individual's
receipt of community mental health rehabilitative services.

G. Utilization review. Utilization reviews for
community-based services for children and adolescents [ underyounger
than ] 21 years of age (Level A) and therapeutic behavioral services
for children and adolescents [ underyounger than ] 21
years of age (Level B) shall include determinations whether providers meet all
DMAS requirements, including compliance with DMAS marketing requirements.
Providers that DMAS determines have violated the DMAS marketing requirements
shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000 E.

H. Utilization review of behavioral therapy services for
children.

1. In order for Medicaid to cover behavioral therapy
services, the provider shall be enrolled with DMAS or its contractor as a
Medicaid provider. The provider enrollment agreement shall be in effect prior
to the delivery of services for Medicaid reimbursement.

2. Behavioral therapy services shall be covered for
individuals younger than 21 years of age when recommended by the individual's
primary care provider, licensed physician, licensed physician assistant, or
licensed nurse practitioner and determined by DMAS or its contractor to be
medically necessary to correct or ameliorate significant impairments in major
life activities that have resulted from either developmental, behavioral, or
mental disabilities.

3. Behavioral therapy services require service
authorization. Services shall be authorized only when eligibility and medical
necessity criteria are met.

4. Prior to treatment, an appropriate service-specific
provider intake shall be conducted, documented, signed, and dated by a licensed
behavior analyst (LBA), licensed assistant behavior analyst (LABA), [ or ]
LMHP, LMHP-R, LMHP-RP, or LMHP-S, acting within the scope of his practice,
documenting the individual's diagnosis (including a description of the
[ behavior or ] behaviors targeted for treatment
with their frequency, duration, and intensity) and describing how service needs
can best be met through behavioral therapy. The service-specific provider
intake shall be conducted face-to-face in the individual's residence with the
individual and parent or guardian. [ A new service-specific
provider intake shall be conducted and documented every three months, or more
often if needed, annually to observe the individual and family
interaction, review clinical data, and revise the ISP as needed. ]

5. The ISP shall be developed upon admission to the service
and reviewed within 30 days of admission to the service to ensure that all
treatment goals are reflective of the individual's clinical needs and shall
describe each treatment goal, targeted behavior, one or more measurable
objectives for each targeted behavior, the behavioral modification strategy to
be used to manage each targeted behavior, the plan for parent or caregiver
training, care coordination, and the measurement and data collection methods to
be used for each targeted behavior in the ISP. The ISP [ as defined
in 12VAC30-50-130 ] shall be fully completed, signed, and dated by
an LBA, LABA, LMHP, LMHP-R, LMHP-RP, or LMHP-S [ and the
individual and individual's parent or guardian. The ISP shall be reviewed every
three months (at the same time the service-specific provider intake is
conducted and documented)and updated as the individual progresses and
his needs change, but at least annually, and shall be signed by either the
parent or legal guardian and the individual. Documentation shall be provided if
the individual, who is a minor child, is unable or unwilling to sign the ISP ].
[ Every three months, the LBA, LABA, LMHP, LMHP-R, LMHP-RP, or LMHP-S
shall review the ISP, modify the ISP as appropriate, and update the ISP, and
all of these activities shall occur with the individual in a manner in which
the individual may participate in the process. The ISP shall be rewritten at
least annually. ]

6. Reimbursement for the initial service-specific provider
intake and the initial ISP shall be limited to five hours without service
authorization. If additional time is needed to complete these documents,
service authorization shall be required.

7. Clinical supervision shall be required for Medicaid
reimbursement of behavioral therapy services that are rendered by an LABA,
LMHP-R, LMHP-RP, or LMHP-S or unlicensed staff consistent with the scope of
practice as described by the applicable Virginia Department of Health
Professions regulatory board. Clinical supervision [ of unlicensed
staff ] shall occur at least weekly [ and, as.
As ] documented in the individual's medical record, [ clinical
supervision ] shall include a review of progress notes and data and
dialogue with supervised staff about the individual's progress and the
effectiveness of the ISP. [ Clinical supervision shall be
documented by, at a minimum, the contemporaneously dated signature of the
clinical supervisor. ]

8. [ Family training involving the individual's
family and significant others to advance the treatment goals of the individual
shall be provided when (i) the training with the family member or significant
other is for the direct benefit of the individual, (ii) the training is not
aimed at addressing the treatment needs of the individual's family or
significant others, (iii) the individual is present except when it is
clinically appropriate for the individual to be absent in order to advance the
individual's treatment goals, and (iv) the training is aligned with the goals
of the individual's treatment plan.

9. ] The following shall not be covered under
this service:

a. Screening to identify physical, mental, or developmental
conditions that may require evaluation or treatment. Screening is covered as an
EPSDT service provided by the primary care provider and is not covered as a
behavioral therapy service under this section.

b. Services other than the initial service-specific
provider intake that are provided but are not based upon the individual's ISP
or linked to a service in the ISP. Time not actively involved in providing
services directed by the ISP shall not be reimbursed.

c. Services that are based upon an incomplete, missing, or
outdated service-specific provider intake or ISP.

d. Sessions that are conducted for family support,
education, recreational, or custodial purposes, including respite or child
care.

e. Services that are provided by a provider but are
rendered primarily by a relative or guardian who is legally responsible for the
individual's care.

f. Services that are provided in a clinic or provider's
office without documented justification for the location in the ISP.

g. Services that are provided in the absence of the
individual [ and or ] a parent or other
authorized caregiver identified in the ISP with the exception of treatment
review processes described in [ 12VAC30-60-61 H 11
subdivision 12 ] e [ of this subsection ],
care coordination, and clinical supervision.

h. Services provided by a local education agency.

i. Provider travel time.

[ 9. 10. ] Behavioral
therapy services shall not be reimbursed concurrently with community mental
health services described in 12VAC30-50-130 B 5 or 12VAC30-50-226, or
behavioral, psychological, or psychiatric therapeutic consultation described in
12VAC30-120-756, 12VAC30-120-1000, or 12VAC30-135-320.

[ 10. 11. ] If the
individual is receiving targeted case management services under the Medicaid
state plan (defined in 12VAC30-50-410 through 12VAC30-50-491, the provider
shall notify the case manager of the provision of behavioral therapy services
unless the parent or guardian requests that the information not be released. In
addition, the provider shall send monthly updates to the case manager on the
individual's status pursuant to a valid release of information. A discharge
summary shall be sent to the case manager within 30 days of the service
discontinuation date. A refusal of the parent or guardian to release
information shall be documented in the medical record for the date the request
was discussed.

[ 11. 12. ] Other standards
to ensure quality of services:

a. Services shall be delivered only by an LBA, LABA, LMHP,
LMHP-R, LMHP-RP, LMHP-S, or clinically supervised unlicensed staff consistent
with the scope of practice as described by the applicable Virginia Department
of Health Professions regulatory board.

b. Individual-specific services shall be directed toward
the treatment of the eligible individual and delivered in the family's
residence unless an alternative location is justified and documented in the
ISP.

c. Individual-specific progress notes shall be created
contemporaneously with the service activities and shall document the name and
Medicaid number of each individual; the provider's name, signature, and date;
and time of service. Documentation shall include activities provided, length of
services provided, the individual's reaction to that day's activity, and
documentation of the individual's and the parent or caregiver's progress toward
achieving each behavioral objective through analysis and reporting of
quantifiable behavioral data. Documentation shall be prepared to clearly
demonstrate efficacy using baseline and service-related data that shows
clinical progress and generalization for the child and family members toward
the therapy goals as defined in the service plan.

d. Documentation of all billed services shall include the
amount of time or billable units spent to deliver the service and shall be
signed and dated on the date of the service by the practitioner rendering the
service.

e. Billable time is permitted for the LBA, LABA, LMHP,
LMHP-R, LMHP-RP, or LMHP-S to better define behaviors and develop documentation
strategies to measure treatment performance and the efficacy of the ISP
objectives, provided that these activities are documented in a progress note as
described in subdivision [ 11 12 ] c of
this subsection.

[ 12. 13. ] Failure to
comply with any of the requirements in 12VAC30-50-130 or in this section shall
result in retraction.

A. Payment for behavioral therapy services for individuals
younger than 21 years of age shall be the lower of the state agency fee
schedule or actual charge (charge to the general public). All private and
governmental fee-for-service providers shall be reimbursed according to the
same methodology. The agency's rates were set as of October 1, 2011, and are
effective for services on or after that date until rates are revised. Rates are
published on the agency's website at http://www.dmas.virginia.gov/.

B. Providers shall be required to refund payments made by
Medicaid if they fail to maintain adequate documentation to support billed
activities.

12VAC30-120-380. MCO responsibilities.

EDITOR'S
NOTE: The proposed amendments to 12VAC30-120-380 were not adopted in the
final regulations; therefore, no changes are made this section.

A. The MCO shall provide, at a
minimum, all medically necessary covered services provided under the State Plan
for Medical Assistance and further defined by written DMAS regulations,
policies and instructions, except as otherwise modified or excluded in this
part.

1. Nonemergency services provided by hospital emergency
departments shall be covered by MCOs in accordance with rates negotiated
between the MCOs and the hospital emergency departments.

2. Services that shall be provided outside the MCO network
shall include [ , but are not limited to, ] those services identified
and defined by the contract between DMAS and the MCO. Services reimbursed by
DMAS include [ (i) ] dental and orthodontic services
for children up to age 21 [ years ]; [ (ii) ]
for all others, dental services (as described in 12VAC30-50-190); [ (iii) ]
school health services; [ (iv) ] community mental
health services (12VAC30-50-130 and 12VAC30-50-226); [ (v) ]
early intervention services provided pursuant to Part C of the Individuals with
Disabilities Education Act (IDEA) of 2004 (as defined in 12VAC30-50-131
[ and 12VAC30-50-415); and ); (vi) ] long-term care services
provided under the § 1915(c) home-based and community-based waivers including
related transportation to such authorized waiver services [ ; and
(vii) behavioral therapy services as defined in 12VAC30-50-130 ].

3. The MCOs shall pay for emergency services and family
planning services and supplies whether such services are provided inside or
outside the MCO network.

B. EPSDT services shall be covered by the MCO and defined by
the contract between DMAS and the MCO. The MCO shall have the authority to determine
the provider of service for EPSDT screenings.

C. The MCOs shall report data to DMAS under the contract
requirements, which may include data reports, report cards for members, and ad
hoc quality studies performed by the MCO or third parties.

D. Documentation requirements.

1. The MCO shall maintain records as required by federal and
state law and regulation and by DMAS policy. The MCO shall furnish such
required information to DMAS, the Attorney General of Virginia or his
authorized representatives, or the State Medicaid Fraud Control Unit on request
and in the form requested.

2. Each MCO shall have written policies regarding member
rights and shall comply with any applicable federal and state laws that pertain
to member rights and shall ensure that its staff and affiliated providers take
those rights into account when furnishing services to members in accordance
with 42 CFR 438.100.

[ 3. Providers shall be required to refund payments
if they fail to maintain adequate documentation to support billed activities. ]

E. The MCO shall ensure that the health care provided to its
members meets all applicable federal and state mandates, community standards
for quality, and standards developed pursuant to the DMAS managed care quality
program.

F. The MCOs shall promptly provide or arrange for the
provision of all required services as specified in the contract between the
Commonwealth and the MCO. Medical evaluations shall be available within 48
hours for urgent care and within 30 calendar days for routine care. On-call
clinicians shall be available 24 hours per day, seven days per week.

G. The MCOs shall meet standards specified by DMAS for
sufficiency of provider networks as specified in the contract between the
Commonwealth and the MCO.

H. Each MCO and its subcontractors shall have in place, and
follow, written policies and procedures for processing requests for initial and
continuing authorizations of service. Each MCO and its subcontractors shall
ensure that any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less than
requested, be made by a health care professional who has appropriate clinical
expertise in treating the member's condition or disease. Each MCO and its
subcontractors shall have in effect mechanisms to ensure consistent application
of review criteria for authorization decisions and shall consult with the
requesting provider when appropriate.

I. In accordance with 42 CFR 447.50 through 42 CFR 447.60,
MCOs shall not impose any cost sharing obligations on members except as set
forth in 12VAC30-20-150 and 12VAC30-20-160.

J. An MCO may not prohibit, or otherwise restrict, a health
care professional acting within the lawful scope of practice, from advising or
advocating on behalf of a member who is his patient in accordance with 42 CFR
438.102.

K. An MCO that would otherwise be required to reimburse for
or provide coverage of a counseling or referral service is not required to do
so if the MCO objects to the service on moral or religious grounds and
furnishes information about the service it does not cover in accordance with 42
CFR 438.102.

The amendments establish Medicaid coverage for behavioral
therapy services for children under the authority of the Early and Periodic
Screening, Diagnosis and Treatment (EPSDT) program. EPSDT is a mandatory
Medicaid-covered service that offers preventive, diagnostic, and treatment
health care services to individuals from birth through the age 21 years. To be
covered for this service, an individual must have a psychiatric diagnosis
relevant to the need for behavioral therapy services, including autism, autism
spectrum disorders, or other similar developmental delays and must meet the
medical necessity criteria. The amendments define the behavioral therapy
service requirements, medical necessity criteria, provider clinical assessment
and intake procedures, service planning and progress measurement requirements,
care coordination, clinical supervision, and other standards to assure quality.
The behavioral therapy service will be reimbursed by the Department of Medical
Assistance Services outside of the Medallion 3 managed care contracts.

The proposed amendments to 12VAC30-120-180 were not adopted
in the final regulation; therefore, managed care organizations are allowed to
provide services. Changes in that section related to documentation will be
addressed in a separate regulatory action.

Summary of Public Comments and Agency's Response: A
summary of comments made by the public and the agency's response may be
obtained from the promulgating agency or viewed at the office of the Registrar
of Regulations.

12VAC30-50-130. Nursing facility services, EPSDT, including
school health services and family planning.

A. Nursing facility services (other than services in an
institution for mental diseases) for individuals 21 years of age or older.
Service must be ordered or prescribed and directed or performed within the
scope of a license of the practitioner of the healing arts.

B. Early and periodic screening and diagnosis of individuals
younger than 21 years of age, and treatment of conditions found.

1. Payment of medical assistance services shall be made on
behalf of individuals younger than 21 years of age, who are Medicaid eligible,
for medically necessary stays in acute care facilities, and the accompanying
attendant physician care, in excess of 21 days per admission when such services
are rendered for the purpose of diagnosis and treatment of health conditions
identified through a physical examination.

2. Routine physicals and immunizations (except as provided
through EPSDT) are not covered except that well-child examinations in a private
physician's office are covered for foster children of the local social services
departments on specific referral from those departments.

3. Orthoptics services shall only be reimbursed if medically
necessary to correct a visual defect identified by an EPSDT examination or
evaluation. The department shall place appropriate utilization controls upon
this service.

4. Consistent with the Omnibus Budget Reconciliation Act of
1989 § 6403, early and periodic screening, diagnostic, and treatment services
means the following services: screening services, vision services, dental
services, hearing services, and such other necessary health care, diagnostic
services, treatment, and other measures described in Social Security Act §
1905(a) to correct or ameliorate defects and physical and mental illnesses and
conditions discovered by the screening services and [ whichthat ]
are medically necessary, whether or not such services are covered under the
State Plan and notwithstanding the limitations, applicable to recipients ages
21 years and older, provided for by § 1905(a) of the Social Security Act.

5. Community mental health services. These services in order to
be covered (i) shall meet medical necessity criteria based upon diagnoses made
by LMHPs who are practicing within the scope of their licenses and (ii) are
reflected in provider records and on providers' claims for services by
recognized diagnosis codes that support and are consistent with the requested
professional services.

a. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context clearly
indicates otherwise:

"Adolescent or child" means the individual receiving
the services described in this section. For the purpose of the use of these
terms, adolescent means an individual 12 through 20 years of age; a child means
an individual from birth up to 12 years of age.

"Behavioral health service" means the same as
defined in 12VAC30-130-5160.

"Behavioral health services administrator" or
"BHSA" means an entity that manages or directs a behavioral health
benefits program under contract with DMAS.

"Care coordination" means collaboration and sharing
of information among health care providers, who are involved with an
individual's health care, to improve the care.

"Caregiver" means the same as defined in
12VAC30-130-5160.

"Certified prescreener" means an employee of the
local community services board or behavioral health authority, or its designee,
who is skilled in the assessment and treatment of mental illness and has
completed a certification program approved by the Department of Behavioral
Health and Developmental Services.

"Clinical experience" means providing direct
behavioral health services on a full-time basis or equivalent hours of
part-time work to children and adolescents who have diagnoses of mental illness
and includes supervised internships, supervised practicums, and supervised
field experience for the purpose of Medicaid reimbursement of (i) intensive
in-home services, (ii) day treatment for children and adolescents, (iii)
community-based residential services for children and adolescents who are
younger than 21 years of age (Level A), or (iv) therapeutic behavioral services
(Level B). Experience shall not include unsupervised internships, unsupervised
practicums, and unsupervised field experience. The equivalency of part-time
hours to full-time hours for the purpose of this requirement shall be as
established by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.

"DBHDS" means the Department of Behavioral Health
and Developmental Services.

"Direct supervisor" means the person who provides
direct supervision to the peer recovery specialist. The direct supervisor (i) shall
have two consecutive years of documented practical experience rendering peer
support services or family support services, have certification training as a
PRS under a certifying body approved by DBHDS, and have documented completion
of the DBHDS PRS supervisor training; (ii) shall be a qualified mental health
professional (QMHP-A, QMHP-C, or QMHP-E) as defined in 12VAC35-105-20 with at
least two consecutive years of documented experience as a QMHP, and who has
documented completion of the DBHDS PRS supervisor training; or (iii) shall be
an LMHP who has documented completion of the DBHDS PRS supervisor training who
is acting within his scope of practice under state law. An LMHP providing
services before April 1, 2018, shall have until April 1, 2018, to complete the
DBHDS PRS supervisor training.

"DMAS" means the Department of Medical Assistance
Services and its [ contractor or ] contractors.

"EPSDT" means early and periodic screening,
diagnosis, and treatment.

"Family support partners" means the same as defined
in 12VAC30-130-5170.

"Human services field" means the same as the term is
defined by DBHDS in the document entitled Human Services and Related Fields
Approved Degrees/Experience, issued March 12, 2013, revised May 3, 2013.

"Individual service plan" or "ISP" means
the same as the term is defined in 12VAC30-50-226.

"Licensed mental health professional" or
"LMHP" means the same as defined in 12VAC35-105-20.

"LMHP-resident" or "LMHP-R" means the same
as "resident" as defined in (i) 18VAC115-20-10 for licensed
professional counselors; (ii) 18VAC115-50-10 for licensed marriage and family
therapists; or (iii) 18VAC115-60-10 for licensed substance abuse treatment
practitioners. An LMHP-resident shall be in continuous compliance with the
regulatory requirements of the applicable counseling profession for supervised
practice and shall not perform the functions of the LMHP-R or be considered a
"resident" until the supervision for specific clinical duties at a
specific site has been preapproved in writing by the Virginia Board of
Counseling. For purposes of Medicaid reimbursement to their supervisors for
services provided by such residents, they shall use the title
"Resident" in connection with the applicable profession after their
signatures to indicate such status.

"LMHP-resident in psychology" or "LMHP-RP"
means the same as an individual in a residency, as that term is defined in
18VAC125-20-10, program for clinical psychologists. An LMHP-resident in
psychology shall be in continuous compliance with the regulatory requirements
for supervised experience as found in 18VAC125-20-65 and shall not perform the
functions of the LMHP-RP or be considered a "resident" until the
supervision for specific clinical duties at a specific site has been
preapproved in writing by the Virginia Board of Psychology. For purposes of
Medicaid reimbursement by supervisors for services provided by such residents,
they shall use the title "Resident in Psychology" after their
signatures to indicate such status.

"LMHP-supervisee in social work,"
"LMHP-supervisee," or "LMHP-S" means the same as
"supervisee" as defined in 18VAC140-20-10 for licensed clinical
social workers. An LMHP-supervisee in social work shall be in continuous
compliance with the regulatory requirements for supervised practice as found in
18VAC140-20-50 and shall not perform the functions of the LMHP-S or be
considered a "supervisee" until the supervision for specific clinical
duties at a specific site is preapproved in writing by the Virginia Board of
Social Work. For purposes of Medicaid reimbursement to their supervisors for
services provided by supervisees, these persons shall use the title
"Supervisee in Social Work" after their signatures to indicate such
status.

"Peer recovery specialist" or "PRS" means
the same as defined in 12VAC30-130-5160.

"Person centered" means the same as defined in
12VAC30-130-5160.

"Progress notes" means individual-specific
documentation that contains the unique differences particular to the
individual's circumstances, treatment, and progress that is also signed and
contemporaneously dated by the provider's professional staff who have prepared
the notes. Individualized and member-specific progress notes are part of the
minimum documentation requirements and shall convey the individual's status, staff
interventions, and, as appropriate, the individual's progress, or lack of
progress, toward goals and objectives in the ISP. The progress notes shall also
include, at a minimum, the name of the service rendered, the date of the
service rendered, the signature and credentials of the person who rendered the
service, the setting in which the service was rendered, and the amount of time
or units/hours required to deliver the service. The content of each progress
note shall corroborate the time/units billed. Progress notes shall be
documented for each service that is billed.

"Psychoeducation" means (i) a specific form of
education aimed at helping individuals who have mental illness and their family
members or caregivers to access clear and concise information about mental
illness and (ii) a way of accessing and learning strategies to deal with mental
illness and its effects in order to design effective treatment plans and
strategies.

"Psychoeducational activities" means systematic
interventions based on supportive and cognitive behavior therapy that
emphasizes an individual's and his family's needs and focuses on increasing the
individual's and family's knowledge about mental disorders, adjusting to mental
illness, communicating and facilitating problem solving and increasing coping
skills.

"Qualified mental health professional-child" or
"QMHP-C" means the same as the term is defined in 12VAC35-105-20.

"Qualified mental health professional-eligible" or
"QMHP-E" means the same as the term is defined in 12VAC35-105-20 and
consistent with the requirements of 12VAC35-105-590.

"Qualified paraprofessional in mental health" or
"QPPMH" means the same as the term is defined in
12VAC35-105-20 and consistent with the requirements of 12VAC35-105-1370.

"Recovery-oriented services" means the same as
defined in 12VAC30-130-5160.

"Recovery, resiliency, and wellness plan" means the
same as defined in 12VAC30-130-5160.

"Resiliency" means the same as defined in
12VAC30-130-5160.

"Self-advocacy" means the same as defined in
12VAC30-130-5160.

"Service-specific provider intake" means the
face-to-face interaction in which the provider obtains information from the
child or adolescent, and parent or other family member [ or members ],
as appropriate, about the child's or adolescent's mental health status. It
includes documented history of the severity, intensity, and duration of mental
health care problems and issues and shall contain all of the following
elements: (i) the presenting issue/reason for referral, (ii) mental health history/hospitalizations,
(iii) previous interventions by providers and timeframes and response to
treatment, (iv) medical profile, (v) developmental history including history of
abuse, if appropriate, (vi) educational/vocational status, (vii) current living
situation and family history and relationships, (viii) legal status, (ix) drug
and alcohol profile, (x) resources and strengths, (xi) mental status exam and
profile, (xii) diagnosis, (xiii) professional summary and clinical formulation,
(xiv) recommended care and treatment goals, and (xv) the dated signature of the
LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP.

"Services provided under arrangement" means the same
as defined in 12VAC30-130-850.

"Strength-based" means the same as defined in
12VAC30-130-5160.

"Supervision" means the same as defined in
12VAC30-130-5160.

b. Intensive in-home services (IIH) to children and
adolescents [ under ageyounger than ] 21 [ years
of age ] shall be time-limited interventions provided in the
individual's residence and when clinically necessary in community settings. All
interventions and the settings of the intervention shall be defined in the
Individual Service Plan. All IIH services shall be designed to specifically
improve family dynamics, provide modeling, and the clinically necessary
interventions that increase functional and therapeutic interpersonal relations
between family members in the home. IIH services are designed to promote
psychoeducational benefits in the home setting of an individual who is at risk
of being moved into an out-of-home placement or who is being transitioned to
home from an out-of-home placement due to a documented medical need of the
individual. These services provide crisis treatment; individual and family
counseling; communication skills (e.g., counseling to assist the individual and
his parents or guardians, as appropriate, to understand and practice
appropriate problem solving, anger management, and interpersonal interaction,
etc.); care coordination with other required services; and 24-hour emergency
response.

(1) [ These services shall be limited annually to 26
weeks. ] Service authorization shall be required for Medicaid
reimbursement prior to the onset of services. Services rendered before the date
of authorization shall not be reimbursed.

[ (2) Service authorization shall be required for
services to continue beyond the initial 26 weeks.

(3)(2) ] Service-specific provider intakes
shall be required at the onset of services and ISPs shall be required during
the entire duration of services. Services based upon incomplete, missing, or
outdated service-specific provider intakes or ISPs shall be denied
reimbursement. Requirements for service-specific provider intakes and ISPs are
set out in this section.

[ (4)(3) ] These services may only be
rendered by an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a
QMHP-E.

c. Therapeutic day treatment (TDT) shall be provided two or
more hours per day in order to provide therapeutic interventions. Day treatment
programs [ , limited annually to 780 units, ] provide
evaluation; medication education and management; opportunities to learn and use
daily living skills and to enhance social and interpersonal skills (e.g.,
problem solving, anger management, community responsibility, increased impulse
control, and appropriate peer relations, etc.); and individual, group and
family counseling.

(1) Service authorization shall be required for Medicaid
reimbursement.

(2) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
service-specific provider intakes and ISPs are set out in this section.

(3) These services may be rendered only by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or a QMHP-E.

d. Community-based services for children and adolescents
[ underyounger than ] 21 years of age (Level A)
pursuant to 42 CFR 440.031(d).

(1) Such services shall be a combination of therapeutic
services rendered in a residential setting. The residential services will
provide structure for daily activities, psychoeducation, therapeutic
supervision, care coordination, and psychiatric treatment to ensure the
attainment of therapeutic mental health goals as identified in the individual
service plan (plan of care). Individuals qualifying for this service must
demonstrate medical necessity for the service arising from a condition due to
mental, behavioral or emotional illness that results in significant functional
impairments in major life activities in the home, school, at work, or in the
community. The service must reasonably be expected to improve the child's
condition or prevent regression so that the services will no longer be needed.
The application of a national standardized set of medical necessity criteria in
use in the industry, such as McKesson InterQual® Criteria or an
equivalent standard authorized in advance by DMAS, shall be required for this
service.

(2) In addition to the residential services, the child must
receive, at least weekly, individual psychotherapy that is provided by an LMHP,
LMHP-supervisee, LMHP-resident, or LMHP-RP.

(3) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.

(4) Authorization shall be required for Medicaid
reimbursement. Services that were rendered before the date of service
authorization shall not be reimbursed.

(5) Room and board costs shall not be reimbursed. DMAS shall
reimburse only for services provided in facilities or programs with no more
than 16 beds.

(6) These residential providers must be licensed by the
Department of Social Services, Department of Juvenile Justice, or Department of
Behavioral Health and Developmental Services under the Standards for Licensed
Children's Residential Facilities (22VAC40-151), Regulation Governing Juvenile
Group Homes and Halfway Houses (6VAC35-41), or Regulations for Children's
Residential Facilities (12VAC35-46).

(7) Daily progress notes shall document a minimum of seven
psychoeducational activities per week. Psychoeducational programming must
include [ , but is not limited to, ] development or
maintenance of daily living skills, anger management, social skills, family
living skills, communication skills, stress management, and any care
coordination activities.

(8) The facility/group home must coordinate services with
other providers. Such care coordination shall be documented in the individual's
medical record. The documentation shall include who was contacted, when the
contact occurred, and what information was transmitted.

(9) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services based upon incomplete, missing, or outdated service-specific
provider intakes or ISPs shall be denied reimbursement. Requirements for
intakes and ISPs are set out in 12VAC30-60-61.

(10) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.

(1) Such services must be therapeutic services rendered in a
residential setting. The residential services will provide structure for daily
activities, psychoeducation, therapeutic supervision, care coordination, and
psychiatric treatment to ensure the attainment of therapeutic mental health
goals as identified in the individual service plan (plan of care). Individuals
qualifying for this service must demonstrate medical necessity for the service
arising from a condition due to mental, behavioral or emotional illness that
results in significant functional impairments in major life activities in the
home, school, at work, or in the community. The service must reasonably be
expected to improve the child's condition or prevent regression so that the
services will no longer be needed. The application of a national standardized
set of medical necessity criteria in use in the industry, such as McKesson
InterQual® Criteria, or an equivalent standard authorized in advance
by DMAS shall be required for this service.

(2) Authorization is required for Medicaid reimbursement.
Services that are rendered before the date of service authorization shall not
be reimbursed.

(3) Room and board costs shall not be reimbursed. Facilities
that only provide independent living services are not reimbursed. DMAS shall
reimburse only for services provided in facilities or programs with no more
than 16 beds.

(4) These residential providers must be licensed by the
Department of Behavioral Health and Developmental Services (DBHDS) under the
Regulations for Children's Residential Facilities (12VAC35-46).

(5) Daily progress notes shall document that a minimum of
seven psychoeducational activities per week occurs. Psychoeducational
programming must include [ , but is not limited to, ]
development or maintenance of daily living skills, anger management, social
skills, family living skills, communication skills, and stress management. This
service may be provided in a program setting or a community-based group home.

(6) The individual must receive, at least weekly, individual
psychotherapy and, at least weekly, group psychotherapy that is provided as
part of the program.

(7) Individuals shall be discharged from this service when
other less intensive services may achieve stabilization.

(8) Service-specific provider intakes shall be required at the
onset of services and ISPs shall be required during the entire duration of
services. Services that are based upon incomplete, missing, or outdated
service-specific provider intakes or ISPs shall be denied reimbursement.
Requirements for intakes and ISPs are set out in 12VAC30-60-61.

(9) These services may only be rendered by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, a QMHP-E, or a QPPMH.

(10) The facility/group home shall coordinate necessary
services with other providers. Documentation of this care coordination shall be
maintained by the facility/group home in the individual's record. The
documentation shall include who was contacted, when the contact occurred, and
what information was transmitted.

f. Mental health family support partners.

(1) Mental health family support partners are peer recovery
support services and are nonclinical, peer-to-peer activities that engage,
educate, and support the caregiver and an individual's self-help efforts to
improve health recovery resiliency and wellness. Mental health family support partners
is a peer support service and is a strength-based, individualized service
provided to the caregiver of a Medicaid-eligible individual younger than 21
years of age with a mental health disorder that is the focus of support. The
services provided to the caregiver and individual must be directed exclusively
toward the benefit of the Medicaid-eligible individual. Services are expected
to improve outcomes for individuals younger than 21 years of age with complex
needs who are involved with multiple systems and increase the individual's and
family's confidence and capacity to manage their own services and supports
while promoting recovery and healthy relationships. These services are rendered
by a PRS who is (i) a parent of a minor or adult child with a similar mental
health disorder or (ii) an adult with personal experience with a family member
with a similar mental health disorder with experience navigating behavioral
health care services. The PRS shall perform the service within the scope of his
knowledge, lived experience, and education.

(2) Under the clinical oversight of the LMHP making the
recommendation for mental health family support partners, the peer recovery
specialist in consultation with his direct supervisor shall develop a recovery,
resiliency, and wellness plan based on the LMHP's recommendation for service,
the individual's and the caregiver's perceived recovery needs, and any clinical
assessments or service specific provider intakes as defined in this section
within 30 calendar days of the initiation of service. Development of the
recovery, resiliency, and wellness plan shall include collaboration with the
individual and the individual's caregiver. Individualized goals and strategies
shall be focused on the individual's identified needs for self-advocacy and
recovery. The recovery, resiliency, and wellness plan shall also include
documentation of how many days per week and how many hours per week are
required to carry out the services in order to meet the goals of the plan. The
recovery, resiliency, and wellness plan shall be completed, signed, and dated
by the LMHP, the PRS, the direct supervisor, the individual, and the
individual's caregiver within 30 calendar days of the initiation of service.
The PRS shall act as an advocate for the individual, encouraging the individual
and the caregiver to take a proactive role in developing and updating goals and
objectives in the individualized recovery planning.

(3) Documentation of required activities shall be required as
set forth in 12VAC30-130-5200 A and C through J.

(4) Limitations and exclusions to service delivery shall be
the same as set forth in 12VAC30-130-5210.

(5) Caregivers of individuals younger than 21 years of age who
qualify to receive mental health family support partners (i) care for an
individual with a mental health disorder who requires recovery assistance and
(ii) meet two or more of the following:

(a) Individual and his caregiver need peer-based
recovery-oriented services for the maintenance of wellness and the acquisition
of skills needed to support the individual.

(b) Individual and his caregiver need assistance to develop
self-advocacy skills to assist the individual in achieving self-management of
the individual's health status.

(c) Individual and his caregiver need assistance and support
to prepare the individual for a successful work or school experience.

(d) Individual and his caregiver need assistance to help the
individual and caregiver assume responsibility for recovery.

(6) Individuals 18 through 20 years of age who meet the
medical necessity criteria in 12VAC30-50-226 B 7 e, who would benefit from
receiving peer supports directly and who choose to receive mental health peer
support services directly instead of through their caregiver, shall be
permitted to receive mental health peer support services by an appropriate PRS.

(7) To qualify for continued mental health family support
partners, the requirements for continued services set forth in 12VAC30-130-5180
D shall be met.

(8) Discharge criteria from mental health family support
partners shall be the same as set forth in 12VAC30-130-5180 E.

(9) Mental health family support partners services shall be
rendered on an individual basis or in a group.

(10) Prior to service initiation, a documented recommendation
for mental health family support partners services shall be made by a licensed
mental health professional (LMHP) who is acting within his scope of practice
under state law. The recommendation shall verify that the individual meets the
medical necessity criteria set forth in subdivision 5 [ a (5) ]
of this subsection. The recommendation shall be valid for no longer than 30
calendar days.

(11) Effective July 1, 2017, a peer recovery specialist shall
have the qualifications, education, experience, and certification required by
DBHDS in order to be eligible to register with the Virginia Board of Counseling
on or after July 1, 2018. Upon the promulgation of regulations by the Board of
Counseling, registration of peer recovery specialists by the Board of
Counseling shall be required. The PRS shall perform mental health family
support partners services under the oversight of the LMHP making the
recommendation for services and providing the clinical oversight of the
recovery, resiliency, and wellness plan.

(12) The PRS shall be employed by or have a contractual
relationship with the enrolled provider licensed for one of the following:

(a) Acute care general and emergency department hospital
services licensed by the Department of Health.

(g) A community mental health and rehabilitative services
provider licensed by the Department of Behavioral Health and Developmental
Services as a provider of one of the following community mental health and
rehabilitative services as defined in this section, 12VAC30-50-226,
12VAC30-50-420, or 12VAC30-50-430 for which the individual younger than 21
years meets medical necessity criteria (i) intensive in home; (ii)
therapeutic day treatment; (iii) day treatment or partial hospitalization;
(iv) crisis intervention; (v) crisis stabilization; (vi) mental health skill
building; or (vii) mental health case management.

(13) Only the licensed and enrolled provider as referenced in
subdivision 5 f (12) of this subsection shall be eligible to bill and receive
reimbursement from DMAS or its contractor for mental health family support
partner services. Payments shall not be permitted to providers that fail to
enter into an enrollment agreement with DMAS or its contractor. Reimbursement
shall be subject to retraction for any billed service that is determined not to
be in compliance with DMAS requirements.

(14) Supervision of the PRS shall be required as set forth in
12VAC30-130-5190 E and 12VAC30-130-5200 G.

6. Inpatient psychiatric services shall be covered for
individuals younger than age 21 for medically necessary stays in inpatient
psychiatric facilities described in 42 CFR 440.160(b)(1) and (b)(2) for the
purpose of diagnosis and treatment of mental health and behavioral disorders
identified under EPSDT when such services are rendered by (i) a psychiatric
hospital or an inpatient psychiatric program in a hospital accredited by the
Joint Commission on Accreditation of Healthcare Organizations; or (ii) a
psychiatric facility that is accredited by the Joint Commission on Accreditation
of Healthcare Organizations or the Commission on Accreditation of
Rehabilitation Facilities. Inpatient psychiatric hospital admissions at general
acute care hospitals and freestanding psychiatric hospitals shall also be
subject to the requirements of 12VAC30-50-100, 12VAC30-50-105, and
12VAC30-60-25. Inpatient psychiatric admissions to residential treatment
facilities shall also be subject to the requirements of Part XIV
(12VAC30-130-850 et seq.) of Amount, Duration and Scope of Selected Services.

a. The inpatient psychiatric services benefit for individuals
younger than 21 years of age shall include services defined at 42 CFR 440.160
that are provided under the direction of a physician pursuant to a
certification of medical necessity and plan of care developed by an
interdisciplinary team of professionals and shall involve active treatment
designed to achieve the child's discharge from inpatient status at the earliest
possible time. The inpatient psychiatric services benefit shall include
services provided under arrangement furnished by Medicaid enrolled providers
other than the inpatient psychiatric facility, as long as the inpatient
psychiatric facility (i) arranges for and oversees the provision of all
services, (ii) maintains all medical records of care furnished to the
individual, and (iii) ensures that the services are furnished under the
direction of a physician. Services provided under arrangement shall be
documented by a written referral from the inpatient psychiatric facility. For
purposes of pharmacy services, a prescription ordered by an employee or
contractor of the facility who is licensed to prescribe drugs shall be
considered the referral.

b. Eligible services provided under arrangement with the
inpatient psychiatric facility shall vary by provider type as described in this
subsection. For purposes of this section, emergency services means the same as
is set out in 12VAC30-50-310 B.

c. Inpatient psychiatric services are reimbursable only when
the treatment program is fully in compliance with (i) 42 CFR Part 441 Subpart
D, specifically 42 CFR 441.151(a) and (b) and [ 42 CFR ]
441.152 through [ 42 CFR ] 441.156, and (ii) the conditions of
participation in 42 CFR Part 483 Subpart G. Each admission must be
preauthorized and the treatment must meet DMAS requirements for clinical
necessity.

d. Service limits may be exceeded based on medical necessity
for individuals eligible for EPSDT.

7. Hearing aids shall be reimbursed for individuals younger
than 21 years of age according to medical necessity when provided by
practitioners licensed to engage in the practice of fitting or dealing in
hearing aids under the Code of Virginia.

9. Services facilitators shall be required for all consumer-directed
personal care services consistent with the requirements set out in
12VAC30-120-935.

10. Behavioral therapy services shall be covered for
individuals [ under the age of younger than ]
21 years [ of age ].

a. Definitions. The following words and terms when used in
this subsection shall have the following meanings unless the context clearly
indicates otherwise:

"Behavioral therapy" means systematic
interventions provided by licensed practitioners acting within the scope of
practice defined under a Virginia [ Department of ] Health
Professions [ Regulatory Board regulatory board ]
and covered as remedial care under 42 CFR 440.130(d) [ within
the home ] to individuals [ under
younger than ] 21 years of age. Behavioral therapy includes applied
behavioral analysis [ and is primarily provided in the family
home ]. Family [ counseling and ] training
related to the implementation of the behavioral therapy shall be included as
part of the behavioral therapy service. Behavioral therapy services shall be subject
to clinical reviews and determined as medically necessary. Behavioral therapy
may be [ intermittently ] provided in
[ the individual's home and ] community settings
[ when approved settings are as ] deemed by
DMAS or its contractor as medically necessary treatment.

[ "Counseling" means a professional mental
health service that can only be provided by a person holding a license issued
by a health regulatory board at the Department of Health Professions, which
includes conducting assessments, making diagnoses of mental disorders and
conditions, establishing treatment plans, and determining treatment
interventions. ]

"Individual" means the child or adolescent
[ under the age of younger than ] 21
[ years of age ] who is receiving behavioral therapy services.

"Primary care provider" means a licensed medical
practitioner who provides preventive and primary health care and is responsible
for providing routine EPSDT screening and referral and coordination of other
medical services needed by the individual.

b. Behavioral therapy services shall be designed to enhance
communication skills and decrease maladaptive patterns of behavior, which if
left untreated, could lead to more complex problems and the need for a greater
or a more intensive level of care. The service goal shall be to ensure the
individual's family or caregiver is trained to effectively manage the
individual's behavior in the home using modification strategies. [ The
All ] services shall be provided in accordance with the [ individual
service plan ISP ] and clinical assessment summary.

c. Behavioral therapy services shall be covered when
recommended by the individual's primary care provider or other licensed
physician, licensed physician assistant, or licensed nurse practitioner and
determined by DMAS or its contractor to be medically necessary to correct or
ameliorate significant impairments in major life activities that have resulted
from either developmental, behavioral, or mental disabilities. Criteria for
medical necessity are set out in 12VAC30-60-61 H. Service-specific provider
intakes shall be required at the onset of these services in order to receive
authorization for reimbursement. Individual service plans (ISPs) shall be
required throughout the entire duration of services. The services shall be
provided in accordance with the individual service plan and clinical assessment
summary. These services shall be provided in settings that are natural or
normal for a child or adolescent without a disability, such as [ his
the individual's ] home, unless there is justification in the ISP,
which has been authorized for reimbursement, to include service settings that
promote a generalization of behaviors across different settings to maintain the
targeted functioning outside of the treatment setting in the [ patient's
residence individual's home ] and the larger community
within which the individual resides. Covered behavioral therapy services shall
include:

2. School divisions may provide routine well-child screening
services under the State Plan. Diagnostic and treatment services that are
otherwise covered under early and periodic screening, diagnosis and treatment
services [ , ] shall not be covered for school divisions.
School divisions to receive reimbursement for the screenings shall be enrolled
with DMAS as clinic providers.

a. Children enrolled in managed care organizations shall
receive screenings from those organizations. School divisions shall not receive
reimbursement for screenings from DMAS for these children.

b. School-based services are listed in a recipient's
individualized education program (IEP) and covered under one or more of the
service categories described in § 1905(a) of the Social Security Act.
These services are necessary to correct or ameliorate defects of physical or
mental illnesses or conditions.

3. Service providersProviders shall be licensed
under the applicable state practice act or comparable licensing criteria by the
Virginia Department of Education [ , ] and shall meet
applicable qualifications under 42 CFR Part 440. Identification of defects,
illnesses or conditions and services necessary to correct or ameliorate them
shall be performed by practitioners qualified to make those determinations
within their licensed scope of practice, either as a member of the IEP team or
by a qualified practitioner outside the IEP team.

a. Service providersProviders shall be employed
by the school division or under contract to the school division.

b. Supervision of services by providers recognized in
subdivision 4 of this subsection shall occur as allowed under federal
regulations and consistent with Virginia law, regulations, and DMAS provider
manuals.

c. The services described in subdivision 4 of this subsection
shall be delivered by school providers, but may also be available in the
community from other providers.

d. Services in this subsection are subject to utilization
control as provided under 42 CFR Parts 455 and 456.

e. The IEP shall determine whether or not the services
described in subdivision 4 of this subsection are medically necessary and that
the treatment prescribed is in accordance with standards of medical practice.
Medical necessity is defined as services ordered by IEP providers. The IEP
providers are qualified Medicaid providers to make the medical necessity
determination in accordance with their scope of practice. The services must be
described as to the amount, duration and scope.

4. Covered services include:

a. Physical therapy, occupational therapy and services for
individuals with speech, hearing, and language disorders, performed by, or
under the direction of, providers who meet the qualifications set forth at 42
CFR 440.110. This coverage includes audiology services.

b. Skilled nursing services are covered under 42 CFR 440.60.
These services are to be rendered in accordance to the licensing standards and
criteria of the Virginia Board of Nursing. Nursing services are to be provided
by licensed registered nurses or licensed practical nurses but may be delegated
by licensed registered nurses in accordance with the regulations of the Virginia
Board of Nursing, especially the section on delegation of nursing tasks and
procedures. The licensed practical nurse is under the supervision of a
registered nurse.

(1) The coverage of skilled nursing services shall be of a
level of complexity and sophistication (based on assessment, planning,
implementation and evaluation) that is consistent with skilled nursing services
when performed by a licensed registered nurse or a licensed practical nurse.
These skilled nursing services shall include [ , but not necessarily be
limited to ] dressing changes, maintaining patent airways, medication
administration/monitoring and urinary catheterizations.

(2) Skilled nursing services shall be directly and
specifically related to an active, written plan of care developed by a
registered nurse that is based on a written order from a physician, physician
assistant or nurse practitioner for skilled nursing services. This order shall
be recertified on an annual basis.

c. Psychiatric and psychological services performed by
licensed practitioners within the scope of practice are defined under state law
or regulations and covered as physicians' services under 42 CFR 440.50 or
medical or other remedial care under 42 CFR 440.60. These outpatient services
include individual medical psychotherapy, group medical psychotherapy coverage,
and family medical psychotherapy. Psychological and neuropsychological testing
are allowed when done for purposes other than educational diagnosis, school
admission, evaluation of an individual with intellectual disability prior to
admission to a nursing facility, or any placement issue. These services are
covered in the nonschool settings also. School providers who may render these
services when licensed by the state include psychiatrists, licensed clinical
psychologists, school psychologists, licensed clinical social workers,
professional counselors, psychiatric clinical nurse specialists, marriage and
family therapists, and school social workers.

d. Personal care services are covered under 42 CFR 440.167 and
performed by persons qualified under this subsection. The personal care
assistant is supervised by a DMAS recognized school-based health professional
who is acting within the scope of licensure. This practitioner develops a
written plan for meeting the needs of the child, which is implemented by the
assistant. The assistant must have qualifications comparable to those for other
personal care aides recognized by the Virginia Department of Medical Assistance
Services. The assistant performs services such as assisting with toileting,
ambulation, and eating. The assistant may serve as an aide on a specially
adapted school vehicle that enables transportation to or from the school or
school contracted provider on days when the student is receiving a
Medicaid-covered service under the IEP. Children requiring an aide during
transportation on a specially adapted vehicle shall have this stated in the
IEP.

e. Medical evaluation services are covered as physicians'
services under 42 CFR 440.50 or as medical or other remedial care under 42 CFR
440.60. Persons performing these services shall be licensed physicians,
physician assistants, or nurse practitioners. These practitioners shall
identify the nature or extent of a child's medical or other health related condition.

f. Transportation is covered as allowed under 42 CFR 431.53
and described at State Plan Attachment 3.1-D (12VAC30-50-530). Transportation
shall be rendered only by school division personnel or contractors.
Transportation is covered for a child who requires transportation on a
specially adapted school vehicle that enables transportation to or from the
school or school contracted provider on days when the student is receiving a
Medicaid-covered service under the IEP. Transportation shall be listed in the
child's IEP. Children requiring an aide during transportation on a specially
adapted vehicle shall have this stated in the IEP.

g. Assessments are covered as necessary to assess or reassess
the need for medical services in a child's IEP and shall be performed by any of
the above licensed practitioners within the scope of practice. Assessments and
reassessments not tied to medical needs of the child shall not be covered.

5. DMAS will ensure through quality management review that
duplication of services will be monitored. School divisions have a
responsibility to ensure that if a child is receiving additional therapy
outside of the school, that there will be coordination of services to avoid
duplication of service.

D. Family planning services and supplies for individuals of
child-bearing age.

1. Service must be ordered or prescribed and directed or
performed within the scope of the license of a practitioner of the healing arts.

2. Family planning services shall be defined as those services
that delay or prevent pregnancy. Coverage of such services shall not include
services to treat infertility or services to promote fertility. Family planning
services shall not cover payment for abortion services and no funds shall be
used to perform, assist, encourage, or make direct referrals for abortions.

3. Family planning services as established by
§ 1905(a)(4)(C) of the Social Security Act include annual family planning
exams; cervical cancer screening for women; sexually transmitted infection
(STI) testing; lab services for family planning and STI testing; family
planning education, counseling, and preconception health; sterilization
procedures; nonemergency transportation to a family planning service; and U.S.
Food and Drug Administration approved prescription and over-the-counter
contraceptives, subject to limits in 12VAC30-50-210.

12VAC30-60-61. Services related to the Early and Periodic
Screening, Diagnosis and Treatment Program (EPSDT); community mental health
[ and behavioral therapy ] services for children [ ;
behavioral therapy services for children ].

A. Definitions. The following words and terms when used in
this section shall have the following meanings unless the context indicates
otherwise:

"At risk" means one or more of the following: (i)
within the two weeks before the intake, the individual shall be screened by an
LMHP for escalating behaviors that have put either the individual or others at
immediate risk of physical injury; (ii) the parent/guardian is unable to manage
the individual's mental, behavioral, or emotional problems in the home and is
actively, within the past two to four weeks, seeking an out-of-home placement;
(iii) a representative of either a juvenile justice agency, a department of
social services (either the state agency or local agency), a community services
board/behavioral health authority, the Department of Education, or an LMHP, as
defined in 12VAC35-105-20, and who is neither an employee of nor consultant to
the intensive in-home (IIH) services or therapeutic day treatment (TDT)
provider, has recommended an out-of-home placement absent an immediate change
of behaviors and when unsuccessful mental health services are evident; (iv) the
individual has a history of unsuccessful services (either crisis intervention,
crisis stabilization, outpatient psychotherapy, outpatient substance abuse
services, or mental health support) within the past 30 days; (v) the treatment
team or family assessment planning team (FAPT) recommends IIH services or TDT
for an individual currently who is either: (a) transitioning out of residential
treatment facility Level C services, (b) transitioning out of a group home
Level A or B services, (c) transitioning out of acute psychiatric
hospitalization, or (d) transitioning between foster homes, mental health case
management, crisis intervention, crisis stabilization, outpatient
psychotherapy, or outpatient substance abuse services.

"Failed services" or "unsuccessful
services" means, as measured by ongoing behavioral, mental, or physical
distress, that the [ service or ] services did not treat or
resolve the individual's mental health or behavioral issues.

"Individual" means the Medicaid-eligible person
receiving these services and for the purpose of this section includes children
from birth up to 12 years of age or adolescents ages 12 through 20 years.

"Licensed assistant behavior analyst" means a
person who has met the licensing requirements of 18VAC85-150 and holds a valid
license issued by the Department of Health Professions.

"Licensed behavior analyst" means a person who
has met the licensing requirements of 18VAC85-150 and holds a valid license
issued by the Department of Health Professions.

"New service" means a community mental health
rehabilitation service for which the individual does not have a current service
authorization in effect as of July 17, 2011.

"Out-of-home placement" means placement in one or
more of the following: (i) either a Level A or Level B group home; (ii) regular
foster home if the individual is currently residing with his biological family
and, due to his behavior problems, is at risk of being placed in the custody of
the local department of social services; (iii) treatment foster care if the
individual is currently residing with his biological family or a regular foster
care family and, due to the individual's behavioral problems, is at risk of
removal to a higher level of care; (iv) Level C residential facility; (v)
emergency shelter for the individual only due either to his mental health or
behavior or both; (vi) psychiatric hospitalization; or (vii) juvenile justice
system or incarceration.

"Service-specific provider intake" means the
evaluation that is conducted according to the Department of Medical Assistance
Services (DMAS) intake definition set out in 12VAC30-50-130.

B. Utilization review requirements for all services in
this section.

1. The services described in this section shall be
rendered consistent with the definitions, service limits, and requirements
described in this section and in 12VAC30-50-130.

2. Providers shall be required to refund payments made by
Medicaid if they fail to maintain adequate documentation to support billed
activities.

3. Individual service plans (ISPs) shall meet all of the
requirements set forth in 12VAC30-60-143 B 7.

C. IntensiveUtilization review of intensive
in-home (IIH) services for children and adolescents.

1. The service definition for intensive in-home (IIH) services
is contained in 12VAC30-50-130.

2. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from mental, behavioral or emotional
illness [ whichthat ] results in significant
functional impairments in major life activities. Individuals must meet at least
two of the following criteria on a continuing or intermittent basis to be
authorized for these services:

a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.

b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services or judicial system
are or have been necessary.

c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.

3. Prior to admission, an appropriate service-specific
provider intake, as defined in 12VAC30-50-130, shall be conducted by the
licensed mental health professional (LMHP), LMHP-supervisee, LMHP-resident, or
LMHP-RP, documenting the individual's diagnosis and describing how service
needs can best be met through intervention provided typically but not solely in
the individual's residence. The service-specific provider intake shall describe
how the individual's clinical needs put the individual at risk of out-of-home
placement and shall be conducted face-to-face in the individual's residence.
Claims for services that are based upon service-specific provider intakes that
are incomplete, outdated (more than 12 months old), or missing shall not be
reimbursed.

4. An individual service plan (ISP) shall be fully completed,
signed, and dated by either an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a
QMHP-C, or a QMHP-E and the individual and individual's parent/guardian within
30 days of initiation of services. The ISP shall meet all of the requirements
as defined in 12VAC30-50-226.

5. DMAS shall not reimburse for dates of services in which the
progress notes are not individualized and child-specific. Duplicated progress
notes shall not constitute the required child-specific individualized progress
notes. Each progress note shall demonstrate unique differences particular to
the individual's circumstances, treatment, and progress. Claim payments shall
be retracted for services that are supported by documentation that does not
demonstrate unique differences particular to the individual.

6. Services shall be directed toward the treatment of the
eligible individual and delivered primarily in the family's residence with the
individual present. As clinically indicated, the services may be rendered in
the community if there is documentation, on that date of service, of the
necessity of providing services in the community. The documentation shall
describe how the alternative community service location supports the identified
clinical needs of the individual and describe how it facilitates the implementation
of the ISP. For services provided outside of the home, there shall be
documentation reflecting therapeutic treatment as set forth in the ISP provided
for that date of service in the appropriately signed and dated progress notes.

7. These services shall be provided when the clinical needs of
the individual put him at risk for out-of-home placement, as these terms are
defined in this section:

a. When services that are far more intensive than outpatient
clinic care are required to stabilize the individual in the family situation,
or

b. When the individual's residence as the setting for services
is more likely to be successful than a clinic.

The service-specific provider intake shall describe how the
individual meets either subdivision a or b of this subdivision [ 7 ].

8. Services shall not be provided if the individual is no
longer a resident of the home.

9. Services shall also be used to facilitate the transition to
home from an out-of-home placement when services more intensive than outpatient
clinic care are required for the transition to be successful. The individual
and responsible parent/guardian shall be available and in agreement to
participate in the transition.

10. At least one parent/legal guardian or responsible adult
with whom the individual is living must be willing to participate in the
intensive in-home services with the goal of keeping the individual with the
family. In the instance of this service, a responsible adult shall be an adult
who lives in the same household with the child and is responsible for engaging
in therapy and service-related activities to benefit the individual.

11. The enrolled service provider shall be licensed by
the Department of Behavioral Health and Developmental Services (DBHDS) as a
provider of intensive in-home services. The provider shall also have a provider
enrollment agreement with DMAS or its contractor in effect prior to the
delivery of this service that indicates that the provider will offer intensive
in-home services.

12. Services must only be provided by an LMHP,
LMHP-supervisee, LMHP-resident, LMHP-RP, QMHP-C, or QMHP-E. Reimbursement shall
not be provided for such services when they have been rendered by a QPPMH as
defined in 12VAC35-105-20.

13. The billing unit for intensive in-home service shall be
one hour. Although the pattern of service delivery may vary, intensive in-home
services is an intensive service provided to individuals for whom there is an
ISP in effect which demonstrates the need for a minimum of three hours a week
of intensive in-home service, and includes a plan for service provision of a
minimum of three hours of service delivery per individual/family per week in
the initial phase of treatment. It is expected that the pattern of service
provision may show more intensive services and more frequent contact with the
individual and family initially with a lessening or tapering off of intensity
toward the latter weeks of service. Service plans shall incorporate an
individualized discharge plan that describes transition from intensive in-home
to less intensive or nonhome based services.

14. The ISP, as defined in 12VAC30-50-226, shall be updated as
the individual's needs and progress changes and signed by either the parent or
legal guardian and the individual. Documentation shall be provided if the
individual, who is a minor child, is unable or unwilling to sign the ISP. If
there is a lapse in services that is greater than 31 consecutive calendar days
without any communications from family members/legal guardian or the individual
with the service provider, the provider shall discharge the individual.
If the individual continues to need services, then a new intake/admission shall
be documented and a new service authorization shall be required.

15. The provider shall ensure that the maximum
staff-to-caseload ratio fully meets the needs of the individual.

16. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the service
provider shall contact the case manager and provide notification of the
provision of services. In addition, the provider shall send monthly updates to
the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 days of the service discontinuation date. Service
providersProviders and case managers who are using the same
electronic health record for the individual shall meet requirements for
delivery of the notification, monthly updates, and discharge summary upon entry
of the information in the electronic health records.

17. Emergency assistance shall be available 24 hours per day,
seven days a week.

19. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or guardian, shall
inform him of the individual's receipt of IIH services. The documentation shall
include who was contacted, when the contact occurred, and what information was
transmitted.

D. TherapeuticUtilization review of therapeutic
day treatment for children and adolescents.

1. The service definition for therapeutic day treatment (TDT)
for children and adolescents is contained in 12VAC30-50-130.

2. Therapeutic day treatment is appropriate for children and
adolescents who meet one of the following:

a. Children and adolescents who require year-round treatment in
order to sustain behavior or emotional gains.

b. Children and adolescents whose behavior and emotional
problems are so severe they cannot be handled in self-contained or resource
emotionally disturbed (ED) classrooms without:

(1) This programming during the school day; or

(2) This programming to supplement the school day or school
year.

c. Children and adolescents who would otherwise be placed on
homebound instruction because of severe emotional/behavior problems that
interfere with learning.

d. Children and adolescents who (i) have deficits in social
skills, peer relations or dealing with authority; (ii) are hyperactive; (iii)
have poor impulse control; (iv) are extremely depressed or marginally connected
with reality.

e. Children in preschool enrichment and early intervention
programs when the children's emotional/behavioral problems are so severe that
they cannot function in these programs without additional services.

3. The service-specific provider intake shall document the
individual's behavior and describe how the individual meets these specific
service criteria in subdivision 2 of this subsection.

4. Prior to admission to this service, a service-specific
provider intake shall be conducted by the LMHP as defined in 12VAC35-105-20.

5. An ISP shall be fully completed, signed, and dated by an
LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, a QMHP-C, or QMHP-E and by the
individual or the parent/guardian within 30 days of initiation of services and
shall meet all requirements of an ISP as defined in 12VAC30-50-226. Individual
progress notes shall be required for each contact with the individual and shall
meet all of the requirements as defined in 12VAC30-50-130.

6. Such services shall not duplicate those services provided
by the school.

7. Individuals qualifying for this service shall demonstrate a
clinical necessity for the service arising from a condition due to mental,
behavioral or emotional illness [ whichthat ] results
in significant functional impairments in major life activities. Individuals
shall meet at least two of the following criteria on a continuing or
intermittent basis:

a. Have difficulty in establishing or maintaining normal
interpersonal relationships to such a degree that they are at risk of
hospitalization or out-of-home placement because of conflicts with family or
community.

b. Exhibit such inappropriate behavior that documented,
repeated interventions by the mental health, social services, or judicial
system are or have been necessary.

c. Exhibit difficulty in cognitive ability such that they are
unable to recognize personal danger or recognize significantly inappropriate
social behavior.

8. The enrolled provider of therapeutic day treatment for child
and adolescent services shall be licensed by DBHDS to provide day support
services. The provider shall also have a provider enrollment agreement in
effect with DMAS prior to the delivery of this service that indicates that the
provider offers therapeutic day treatment services for children and
adolescents.

10. The minimum staff-to-individual ratio as defined by DBHDS
licensing requirements shall ensure that adequate staff is available to meet
the needs of the individual identified on the ISP.

11. The program shall operate a minimum of two hours per day
and may offer flexible program hours (i.e., before or after school or during
the summer). One unit of service shall be defined as a minimum of two hours but
less than three hours in a given day. Two units of service shall be defined as
a minimum of three but less than five hours in a given day. Three units of
service shall be defined as five or more hours of service in a given day.

12. Time required for academic instruction when no treatment
activity is going on shall not be included in the billing unit.

13. Services shall be provided following a service-specific
provider intake that is conducted by an LMHP, LMHP-supervisee, LMHP-resident,
or LMHP-RP. An LMHP, LMHP-supervisee, or LMHP-resident shall make and document
the diagnosis. The service-specific provider intake shall include the elements
as defined in 12VAC30-50-130.

14. If an individual receiving services is also receiving case
management services pursuant to 12VAC30-50-420 or 12VAC30-50-430, the provider
shall collaborate with the case manager and provide notification of the
provision of services. In addition, the provider shall send monthly updates to
the case manager on the individual's status. A discharge summary shall be sent
to the case manager within 30 days of the service discontinuation date. Service
providersProviders and case managers using the same electronic
health record for the individual shall meet requirements for delivery of the
notification, monthly updates, and discharge summary upon entry of this
documentation into the electronic health record.

15. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
guardian, shall inform [ himthe primary care provider ]
of the child's receipt of community mental health rehabilitative services. The
documentation shall include who was contacted, when the contact occurred, and
what information was transmitted. The parent/legal guardian shall be required
to give written consent that this provider has permission to inform the primary
care provider of the child's or adolescent's receipt of community mental health
rehabilitative services.

16. Providers shall comply with DMAS marketing requirements as
set out in 12VAC30-130-2000. Providers that DMAS determines have violated these
marketing requirements shall be terminated as a Medicaid provider pursuant to
12VAC30-130-2000 E.

17. If there is a lapse in services greater than 31
consecutive calendar days, the provider shall discharge the individual. If the
individual continues to need services, a new intake/admission documentation
shall be prepared and a new service authorization shall be required.

E. Community-basedUtilization review of
community-based services for children and adolescents [ underyounger
than ] 21 years of age (Level A).

1. The staff ratio must be at least [ 1one ]
to [ 6six ] during the day and at least [ 1one ] to 10 between 11 p.m. and 7 a.m. The program director
supervising the program/group home must be, at minimum, a QMHP-C or QMHP-E (as
defined in 12VAC35-105-20). The program director must be employed full time.

2. In order for Medicaid reimbursement to be approved, at
least 50% of the provider's direct care staff at the group home must meet DBHDS
paraprofessional staff criteria, defined in 12VAC35-105-20.

3. Authorization is required for Medicaid reimbursement. All
community-based services for children and adolescents [ underyounger
than ] 21 (Level A) require authorization prior to reimbursement for
these services. Reimbursement shall not be made for this service when other
less intensive services may achieve stabilization.

4. Services must be provided in accordance with an individual
service plan (ISP), which must be fully completed within 30 days of
authorization for Medicaid reimbursement.

5. Prior to admission, a service-specific provider intake
shall be conducted according to DMAS specifications described in
12VAC30-50-130.

6. Such service-specific provider intakes shall be performed
by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.

7. If an individual receiving community-based services for
children and adolescents [ underyounger than ] 21
[ years of age ] (Level A) is also receiving case management
services, the provider shall collaborate with the case manager by notifying the
case manager of the provision of Level A services and shall send monthly
updates on the individual's progress. When the individual is discharged from
Level A services, a discharge summary shall be sent to the case manager within
30 days of the service discontinuation date. Service providersProviders
and case managers who are using the same electronic health record for the
individual shall meet requirements for the delivery of the notification,
monthly updates, and discharge summary upon entry of this documentation into
the electronic health record.

F. TherapeuticUtilization review of therapeutic
behavioral services for children and adolescents [ underyounger
than ] 21 years of age (Level B).

1. The staff ratio must be at least [ 1one ]
to [ 4four ] during the day and at least [ 1one ] to [ 8eight ] between 11 p.m. and 7
a.m. The clinical director must be a licensed mental health professional. The
caseload of the clinical director must not exceed 16 individuals including all
sites for which the same clinical director is responsible.

2. The program director must be full time and be a QMHP-C or
QMHP-E with a bachelor's degree and at least one year's clinical experience.

3. For Medicaid reimbursement to be approved, at least 50% of
the provider's direct care staff at the group home shall meet DBHDS
paraprofessional staff criteria, as defined in 12VAC35-105-20. The
program/group home must coordinate services with other providers.

4. All therapeutic behavioral services (Level B) shall be
authorized prior to reimbursement for these services. Services rendered without
such prior authorization shall not be covered.

5. Services must be provided in accordance with an ISP, which
shall be fully completed within 30 days of authorization for Medicaid
reimbursement.

6. Prior to admission, a service-specific provider intake
shall be performed using all elements specified by DMAS in 12VAC30-50-130.

7. Such service-specific provider intakes shall be performed
by an LMHP, an LMHP-supervisee, LMHP-resident, or LMHP-RP.

8. If an individual receiving therapeutic behavioral services
for children and adolescents [ underyounger than ] 21
[ years of age ] (Level B) is also receiving case management
services, the therapeutic behavioral services provider must collaborate with
the care coordinator/case manager by notifying him of the provision of Level B
services and the Level B services provider shall send monthly updates on the
individual's treatment status. When the individual is discharged from Level B
services, a discharge summary shall be sent to the care coordinator/case
manager within 30 days of the discontinuation date.

9. The provider shall determine who the primary care provider
is and, upon receiving written consent from the individual or parent/legal
guardian, shall inform [ himthe primary care provider ]
of the individual's receipt of these Level B services. The documentation shall
include who was contacted, when the contact occurred, and what information was
transmitted. If these individuals are children or adolescents, then the
parent/legal guardian shall be required to give written consent that this
provider has permission to inform the primary care provider of the individual's
receipt of community mental health rehabilitative services.

G. Utilization review. Utilization reviews for
community-based services for children and adolescents [ underyounger
than ] 21 years of age (Level A) and therapeutic behavioral services
for children and adolescents [ underyounger than ] 21
years of age (Level B) shall include determinations whether providers meet all
DMAS requirements, including compliance with DMAS marketing requirements.
Providers that DMAS determines have violated the DMAS marketing requirements
shall be terminated as a Medicaid provider pursuant to 12VAC30-130-2000 E.

H. Utilization review of behavioral therapy services for
children.

1. In order for Medicaid to cover behavioral therapy
services, the provider shall be enrolled with DMAS or its contractor as a
Medicaid provider. The provider enrollment agreement shall be in effect prior
to the delivery of services for Medicaid reimbursement.

2. Behavioral therapy services shall be covered for
individuals younger than 21 years of age when recommended by the individual's
primary care provider, licensed physician, licensed physician assistant, or
licensed nurse practitioner and determined by DMAS or its contractor to be
medically necessary to correct or ameliorate significant impairments in major
life activities that have resulted from either developmental, behavioral, or
mental disabilities.

3. Behavioral therapy services require service
authorization. Services shall be authorized only when eligibility and medical
necessity criteria are met.

4. Prior to treatment, an appropriate service-specific
provider intake shall be conducted, documented, signed, and dated by a licensed
behavior analyst (LBA), licensed assistant behavior analyst (LABA), [ or ]
LMHP, LMHP-R, LMHP-RP, or LMHP-S, acting within the scope of his practice,
documenting the individual's diagnosis (including a description of the
[ behavior or ] behaviors targeted for treatment
with their frequency, duration, and intensity) and describing how service needs
can best be met through behavioral therapy. The service-specific provider
intake shall be conducted face-to-face in the individual's residence with the
individual and parent or guardian. [ A new service-specific
provider intake shall be conducted and documented every three months, or more
often if needed, annually to observe the individual and family
interaction, review clinical data, and revise the ISP as needed. ]

5. The ISP shall be developed upon admission to the service
and reviewed within 30 days of admission to the service to ensure that all
treatment goals are reflective of the individual's clinical needs and shall
describe each treatment goal, targeted behavior, one or more measurable
objectives for each targeted behavior, the behavioral modification strategy to
be used to manage each targeted behavior, the plan for parent or caregiver
training, care coordination, and the measurement and data collection methods to
be used for each targeted behavior in the ISP. The ISP [ as defined
in 12VAC30-50-130 ] shall be fully completed, signed, and dated by
an LBA, LABA, LMHP, LMHP-R, LMHP-RP, or LMHP-S [ and the
individual and individual's parent or guardian. The ISP shall be reviewed every
three months (at the same time the service-specific provider intake is
conducted and documented)and updated as the individual progresses and
his needs change, but at least annually, and shall be signed by either the
parent or legal guardian and the individual. Documentation shall be provided if
the individual, who is a minor child, is unable or unwilling to sign the ISP ].
[ Every three months, the LBA, LABA, LMHP, LMHP-R, LMHP-RP, or LMHP-S
shall review the ISP, modify the ISP as appropriate, and update the ISP, and
all of these activities shall occur with the individual in a manner in which
the individual may participate in the process. The ISP shall be rewritten at
least annually. ]

6. Reimbursement for the initial service-specific provider
intake and the initial ISP shall be limited to five hours without service
authorization. If additional time is needed to complete these documents,
service authorization shall be required.

7. Clinical supervision shall be required for Medicaid
reimbursement of behavioral therapy services that are rendered by an LABA,
LMHP-R, LMHP-RP, or LMHP-S or unlicensed staff consistent with the scope of
practice as described by the applicable Virginia Department of Health
Professions regulatory board. Clinical supervision [ of unlicensed
staff ] shall occur at least weekly [ and, as.
As ] documented in the individual's medical record, [ clinical
supervision ] shall include a review of progress notes and data and
dialogue with supervised staff about the individual's progress and the
effectiveness of the ISP. [ Clinical supervision shall be
documented by, at a minimum, the contemporaneously dated signature of the
clinical supervisor. ]

8. [ Family training involving the individual's
family and significant others to advance the treatment goals of the individual
shall be provided when (i) the training with the family member or significant
other is for the direct benefit of the individual, (ii) the training is not
aimed at addressing the treatment needs of the individual's family or
significant others, (iii) the individual is present except when it is
clinically appropriate for the individual to be absent in order to advance the
individual's treatment goals, and (iv) the training is aligned with the goals
of the individual's treatment plan.

9. ] The following shall not be covered under
this service:

a. Screening to identify physical, mental, or developmental
conditions that may require evaluation or treatment. Screening is covered as an
EPSDT service provided by the primary care provider and is not covered as a
behavioral therapy service under this section.

b. Services other than the initial service-specific
provider intake that are provided but are not based upon the individual's ISP
or linked to a service in the ISP. Time not actively involved in providing
services directed by the ISP shall not be reimbursed.

c. Services that are based upon an incomplete, missing, or
outdated service-specific provider intake or ISP.

d. Sessions that are conducted for family support,
education, recreational, or custodial purposes, including respite or child
care.

e. Services that are provided by a provider but are
rendered primarily by a relative or guardian who is legally responsible for the
individual's care.

f. Services that are provided in a clinic or provider's
office without documented justification for the location in the ISP.

g. Services that are provided in the absence of the
individual [ and or ] a parent or other
authorized caregiver identified in the ISP with the exception of treatment
review processes described in [ 12VAC30-60-61 H 11
subdivision 12 ] e [ of this subsection ],
care coordination, and clinical supervision.

h. Services provided by a local education agency.

i. Provider travel time.

[ 9. 10. ] Behavioral
therapy services shall not be reimbursed concurrently with community mental
health services described in 12VAC30-50-130 B 5 or 12VAC30-50-226, or
behavioral, psychological, or psychiatric therapeutic consultation described in
12VAC30-120-756, 12VAC30-120-1000, or 12VAC30-135-320.

[ 10. 11. ] If the
individual is receiving targeted case management services under the Medicaid
state plan (defined in 12VAC30-50-410 through 12VAC30-50-491, the provider
shall notify the case manager of the provision of behavioral therapy services
unless the parent or guardian requests that the information not be released. In
addition, the provider shall send monthly updates to the case manager on the
individual's status pursuant to a valid release of information. A discharge
summary shall be sent to the case manager within 30 days of the service
discontinuation date. A refusal of the parent or guardian to release
information shall be documented in the medical record for the date the request
was discussed.

[ 11. 12. ] Other standards
to ensure quality of services:

a. Services shall be delivered only by an LBA, LABA, LMHP,
LMHP-R, LMHP-RP, LMHP-S, or clinically supervised unlicensed staff consistent
with the scope of practice as described by the applicable Virginia Department
of Health Professions regulatory board.

b. Individual-specific services shall be directed toward
the treatment of the eligible individual and delivered in the family's
residence unless an alternative location is justified and documented in the
ISP.

c. Individual-specific progress notes shall be created
contemporaneously with the service activities and shall document the name and
Medicaid number of each individual; the provider's name, signature, and date;
and time of service. Documentation shall include activities provided, length of
services provided, the individual's reaction to that day's activity, and
documentation of the individual's and the parent or caregiver's progress toward
achieving each behavioral objective through analysis and reporting of
quantifiable behavioral data. Documentation shall be prepared to clearly
demonstrate efficacy using baseline and service-related data that shows
clinical progress and generalization for the child and family members toward
the therapy goals as defined in the service plan.

d. Documentation of all billed services shall include the
amount of time or billable units spent to deliver the service and shall be
signed and dated on the date of the service by the practitioner rendering the
service.

e. Billable time is permitted for the LBA, LABA, LMHP,
LMHP-R, LMHP-RP, or LMHP-S to better define behaviors and develop documentation
strategies to measure treatment performance and the efficacy of the ISP
objectives, provided that these activities are documented in a progress note as
described in subdivision [ 11 12 ] c of
this subsection.

[ 12. 13. ] Failure to
comply with any of the requirements in 12VAC30-50-130 or in this section shall
result in retraction.

A. Payment for behavioral therapy services for individuals
younger than 21 years of age shall be the lower of the state agency fee
schedule or actual charge (charge to the general public). All private and
governmental fee-for-service providers shall be reimbursed according to the
same methodology. The agency's rates were set as of October 1, 2011, and are
effective for services on or after that date until rates are revised. Rates are
published on the agency's website at http://www.dmas.virginia.gov/.

B. Providers shall be required to refund payments made by
Medicaid if they fail to maintain adequate documentation to support billed
activities.

12VAC30-120-380. MCO responsibilities.

EDITOR'S
NOTE: The proposed amendments to 12VAC30-120-380 were not adopted in the
final regulations; therefore, no changes are made this section.

A. The MCO shall provide, at a
minimum, all medically necessary covered services provided under the State Plan
for Medical Assistance and further defined by written DMAS regulations,
policies and instructions, except as otherwise modified or excluded in this
part.

1. Nonemergency services provided by hospital emergency
departments shall be covered by MCOs in accordance with rates negotiated
between the MCOs and the hospital emergency departments.

2. Services that shall be provided outside the MCO network
shall include [ , but are not limited to, ] those services identified
and defined by the contract between DMAS and the MCO. Services reimbursed by
DMAS include [ (i) ] dental and orthodontic services
for children up to age 21 [ years ]; [ (ii) ]
for all others, dental services (as described in 12VAC30-50-190); [ (iii) ]
school health services; [ (iv) ] community mental
health services (12VAC30-50-130 and 12VAC30-50-226); [ (v) ]
early intervention services provided pursuant to Part C of the Individuals with
Disabilities Education Act (IDEA) of 2004 (as defined in 12VAC30-50-131
[ and 12VAC30-50-415); and ); (vi) ] long-term care services
provided under the § 1915(c) home-based and community-based waivers including
related transportation to such authorized waiver services [ ; and
(vii) behavioral therapy services as defined in 12VAC30-50-130 ].

3. The MCOs shall pay for emergency services and family
planning services and supplies whether such services are provided inside or
outside the MCO network.

B. EPSDT services shall be covered by the MCO and defined by
the contract between DMAS and the MCO. The MCO shall have the authority to determine
the provider of service for EPSDT screenings.

C. The MCOs shall report data to DMAS under the contract
requirements, which may include data reports, report cards for members, and ad
hoc quality studies performed by the MCO or third parties.

D. Documentation requirements.

1. The MCO shall maintain records as required by federal and
state law and regulation and by DMAS policy. The MCO shall furnish such
required information to DMAS, the Attorney General of Virginia or his
authorized representatives, or the State Medicaid Fraud Control Unit on request
and in the form requested.

2. Each MCO shall have written policies regarding member
rights and shall comply with any applicable federal and state laws that pertain
to member rights and shall ensure that its staff and affiliated providers take
those rights into account when furnishing services to members in accordance
with 42 CFR 438.100.

[ 3. Providers shall be required to refund payments
if they fail to maintain adequate documentation to support billed activities. ]

E. The MCO shall ensure that the health care provided to its
members meets all applicable federal and state mandates, community standards
for quality, and standards developed pursuant to the DMAS managed care quality
program.

F. The MCOs shall promptly provide or arrange for the
provision of all required services as specified in the contract between the
Commonwealth and the MCO. Medical evaluations shall be available within 48
hours for urgent care and within 30 calendar days for routine care. On-call
clinicians shall be available 24 hours per day, seven days per week.

G. The MCOs shall meet standards specified by DMAS for
sufficiency of provider networks as specified in the contract between the
Commonwealth and the MCO.

H. Each MCO and its subcontractors shall have in place, and
follow, written policies and procedures for processing requests for initial and
continuing authorizations of service. Each MCO and its subcontractors shall
ensure that any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less than
requested, be made by a health care professional who has appropriate clinical
expertise in treating the member's condition or disease. Each MCO and its
subcontractors shall have in effect mechanisms to ensure consistent application
of review criteria for authorization decisions and shall consult with the
requesting provider when appropriate.

I. In accordance with 42 CFR 447.50 through 42 CFR 447.60,
MCOs shall not impose any cost sharing obligations on members except as set
forth in 12VAC30-20-150 and 12VAC30-20-160.

J. An MCO may not prohibit, or otherwise restrict, a health
care professional acting within the lawful scope of practice, from advising or
advocating on behalf of a member who is his patient in accordance with 42 CFR
438.102.

K. An MCO that would otherwise be required to reimburse for
or provide coverage of a counseling or referral service is not required to do
so if the MCO objects to the service on moral or religious grounds and
furnishes information about the service it does not cover in accordance with 42
CFR 438.102.

VA.R. Doc. No. R13-3527; Filed October 23, 2018, 10:33 a.m.

TITLE 12. HEALTH

STATE BOARD OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES

Fast-Track Regulation

Title of Regulation: 12VAC35-190. Regulations for
Voluntary Admissions to State Training Centers (amending 12VAC35-190-10, 12VAC35-190-21,
12VAC35-190-30).

Statutory Authority: §§ 37.2-203 and 37.2-806 of the
Code of Virginia.

Basis: Section 37.2-203 of the Code of Virginia
authorizes the State Board of Behavioral Health and Developmental Services to
adopt regulations that may be necessary to carry out the provisions of Title
37.2 of the Code of Virginia and other laws of the Commonwealth administered by
the commissioner and the department.

Purpose: This action is the result of a periodic review.
No comments were received during the review. With only two exceptions the
amendments are not substantive and merely update language to mirror language in
the Code of Virginia or in 12VAC35-115, Regulations to Assure the Rights of
Individuals Receiving Services from Providers Licensed, Funded, or Operated by
the Department of Behavioral Health and Developmental Services. The two
substantive changes are (i) the addition of the definition of "regional
support team" (RST) and the function of the RST to the discharge planning
process, which is initiated at admission, and (ii) the addition of the
assistant commissioner having responsibility for the training center as part of
the admission process. These two changes mirror practices that have been in
place since 2012.

Rationale for Using Fast-Track Rulemaking Process: This
action is the result of a periodic review. No comments were received during the
review. The amendments merely update language to mirror current language in
state law, regulation, or practices that have been in place since 2012.

Substance: The amendments (i) update definitions of
authorized representative, community services board, and training center; (ii)
add definitions of department, intellectual disability, individual, and
regional support team; (iii) add "in consultation with" in two
sections to include RSTs in the process described in 12VAC35-190-21 regarding
applications for admission and the assistant commissioner having responsibility
for the training center in 12VAC35-190-30 regarding the criteria for admission;
and (iv) delete the definition for "mental retardation" and the term
throughout the regulation.

Issues: This action is the result of a periodic review,
which includes a public comment period. The proposed amendments will provide
clarity for interested stakeholders and the system by providing updated
language to mirror language in the Code of Virginia, 12VAC35-115, and current
practice.

Small Business Impact Review Report of Findings: This
fast-track regulatory action serves as the report of the findings of the
regulatory review pursuant to § 2.2-4007.1 of the Code of Virginia.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. As the result
of a periodic review,1 the State Board of
Behavioral Health and Developmental Services (Board) proposes to: 1) add a
definition for "regional support team" (RST),2
2) specify that community services boards (CSB) must consult with the RST prior
to preparing a preadmission screening to a state training center,3 3) specify that the director of the training
center consult with the assistant commissioner responsible for the training
center in determining whether admission is appropriate, and 4) update language
to mirror language in § 37.2-100 of the Code of Virginia4
or in 12VAC35-115, Regulations to Assure the Rights of Individuals Receiving
Services from Providers Licensed, Funded, or Operated by the Department Of
Behavioral Health and Developmental Services.5

Result of Analysis. The benefits likely exceed the costs for
the proposed regulation.

Estimated Economic Impact:

Background. The Regulations for Voluntary Admissions to State
Training Centers are designed to: 1) inform individuals, authorized
representatives, Department of Behavioral Health and Developmental Services
(DBHDS) employees, community services board staff, and pertinent stakeholders
of the process and procedures related to admitting individuals with
intellectual disabilities to state training centers, 2) educate responsible
persons on the approved criteria for admission to training centers, and 3)
inform individuals and authorized representatives of the appeal process if they
should disagree with the admission decision.

In 2012, the federal government and Virginia entered into a
settlement agreement6 concerning how the
Commonwealth provides services to its intellectually and developmentally
disabled population. As a result of that settlement agreement, RSTs were then
created, and CSBs were required to consult with the RST prior to preparing a
preadmission screening to a state training center. Additionally, the director
of training centers have been required to consult with the assistant
commissioner responsible for the training center in determining whether
admission is appropriate.

Analysis. The proposal to update language to mirror the Code of
Virginia and 12VAC35-115 provides improved clarity and does not affect
requirements in practice. The existence of and requirement for consultation
with RSTs, and the requirement for consultation with the assistant
commissioner, have been legally required through the settlement agreement since
2012. Thus, the only impact of the proposed language amendments would be to
better inform the public of current legal requirements and procedures.
Consequently, the benefits of the proposed amendments exceed the costs.

Projected Impact on Employment. The proposed amendments do not
affect employment.

Effects on the Use and Value of Private Property. The proposed
amendments do not affect the user and value of private property.

Real Estate Development Costs. The proposed amendments do not
affect real estate development costs.

Small Businesses:

Definition

Pursuant to § 2.2-4007.04 of the
Code of Virginia, small business is defined as "a business entity,
including its affiliates, that (i) is independently owned and operated and (ii)
employs fewer than 500 full-time employees or has gross annual sales of less
than $6 million."

Costs and Other Effects. The
proposed amendments do not affect costs for small businesses.

Alternative Method that Minimizes
Adverse Impact. The proposed amendments do not adversely affect small
businesses.

Adverse Impacts:

Businesses. The proposed
amendments do not adversely affect businesses.

Localities. The proposed
amendments do not adversely affect localities.

Other Entities. The proposed
amendments do not adversely affect other entities.

2Regional support team is defined as "a group of
professionals with expertise in serving individuals with developmental disabilities
in the community appointed by the commissioner or his designee who provide
recommendations to support placement in the most integrated setting appropriate
to an individual's needs and consistent with the individual's informed
choice."

3Training center is defined as "a facility operated
by (DBHDS) that provides training, habilitation, or other individually focused
supports to persons with intellectual disability."

Agency's Response to Economic Impact Analysis: The
Department of Behavioral Health and Developmental Services concurs with the
economic impact analysis.

Summary:

The amendments (i) specify that community services boards must
consult with the regional support team regarding admissions, (ii) specify that
the director of the training center consult with the assistant commissioner
responsible for the training center in determining eligibility for admission,
and (iii) update language.

12VAC35-190-10. Definitions.

The following words and terms when used in this chapter shall
have the following meanings unless the context clearly indicates otherwise:

"Admission" means acceptance of an individual in a
training center.

"Authorized representative" or "AR"
means a person permitted by law or regulation to authorize the disclosure of
information or to consent to treatment and services, including
medical treatment, or the participation in human research on
behalf of an individual who lacks the mental capacity to make these decisions.

"Commissioner" means the Commissioner of the
Department of Behavioral Health and Developmental Services.

"Community services board" or "CSB" means
the public body established pursuant to § 37.2-501 of the Code of Virginia
that provides mental health, developmental, and substance abuse services to
individuals within each city and county that established it. For the
purpose of these regulationsthis chapter, CSB also includes a
behavioral health authority established pursuant to § 37.2-602 of the Code
of Virginia.

"Department" means the Department of Behavioral
Health and Developmental Services.

"Discharge plan" means a written plan prepared by
the CSB providing case management in consultation with the training center
pursuant to §§ 37.2-505 and 37.2-837 of the Code of Virginia. This plan is
prepared when the individual is admitted to the training center and documents
the services to be provided upon discharge.

"Guardian" means:

1. For Minorsminors -- an adult who is
either appointed by the court as a legal guardian of a minor or exercises the
rights and responsibilities of legal custody by delegation from a biological or
adoptive parent, upon provisional adoption or otherwise by operation of law.

2. For Adultsadults -- a person
appointed by the court who is responsible for the personal affairs of an
incapacitated adult under the order of appointment. The responsibilities may
include making decisions regarding the individual's support, care, health,
safety, habilitation, education and therapeutic treatment. Refer to definition
of "incapacitated person" at § 37.2-100064.2-2000 of
the Code of Virginia.

"Individual" means a person with an intellectual
disability for whom services are sought. This term includes the terms
"consumer," "patient," "resident," and
"client."

"Intellectual disability" means a disability
originating before the age of 18 years, characterized concurrently by (i)
significant subaverage intellectual functioning as demonstrated by performance
on a standardized measure of intellectual functioning administered in
conformity with accepted professional practice that is at least two standard
deviations below the mean; and (ii) significant limitations in adaptive
behavior as expressed in conceptual, social, and practical adaptive skills.

"Licensed professional" means a licensed
psychologist, licensed professional counselor, or other individual who holds a
valid professional license and has appropriate training in intellectual
testing.

"Mental retardation" ("intellectual
disability") means a disability originating before the age of 18 years,
characterized concurrently by (i) significantly subaverage intellectual
functioning as demonstrated by performance on a standardized measure of
intellectual functioning, administered in conformity with accepted professional
practice, that is at least two standard deviations below the mean; and (ii)
significant limitations in adaptive behavior as expressed in conceptual,
social, and practical adaptive skills.

"Regional support team" or "RST" means
a group of professionals with expertise in serving individuals with
developmental disabilities in the community appointed by the commissioner or
the commissioner's designee who provide recommendations to support placement in
the most integrated setting appropriate to an individual's needs and consistent
with the individual's informed choice.

"Training center" means a facility operated by the Department
of Behavioral Health and Developmental Servicesfor the treatment,department
that provides training, or habilitation of, or other
individually focused supports to persons with mental retardation
(intellectual disability)intellectual disabilities.

12VAC35-190-21. Application for admission.

A. Requests for admission to a training center shall be
processed through the CSB. A parent, guardian, or authorized representative
seeking admission to a training center for an individual with mental
retardation (intellectual disability)an intellectual disability
shall apply first to the CSB that serves the area where the individual, or if a
minor, histhe minor's parent or guardian is currently residing. The
CSB shall consult with the RST prior to preparing a preadmission screening.

B. If the CSB, in consultation with the RST,
determines that the services for the individual are not available in the
community or the individual chooses to obtain services in the state training
center, the CSB shall forward a preadmission screening report, pursuant to §
37.2-806 B of the Code of Virginia, to thea training center
serving individuals with mental retardation (intellectual disability) from
that geographic section of the state in which the individual or, if a minor,
his parent or guardian is currently residingintellectual disabilities.

C. The preadmission screening report shall include at a
minimum:

1. An application for services;

2. A medical history indicating the presence of any current
medical problems as well as the presence of any known communicable disease. In
all cases, the application shall include any currently prescribed medications
as well as any known medication allergies;

3. A social history and current housing or living
arrangements; and

4. A psychological evaluation that reflects the individual's
current functioning.

D. The preadmission screening report shall also include the
following, as appropriate:

1. A current individualized education plan for school-aged
individuals.

2. A vocational assessment for adults.

3. A completed discharge plan outlining the services to be
provided upon discharge and anticipated date of discharge.

4. A statement from the individual, family member, or
authorized representative requesting services in the training center.

12VAC35-190-30. Criteria for admission.

A. Upon the receipt of a completed preadmission screening
report, the director of the training center or designee shall determine
eligibility for admission based upon the following criteria:

1. The individual has a diagnosis of mental retardation
(intellectual disability)an intellectual disability;

2. The diagnosis of mental retardationan
intellectual disability has been made by a licensed professional; and

3. The training center has available space and service
capacity to meet the needs of the individual.

B. If the director, in consultation with the assistant
commissioner responsible for the training center or his designee, finds
that admission is not appropriate, hethe director shall state
the reasons in a written decision and may recommend an alternative location for
needed services.

C. Within 10 working days from the receipt of the completed
preadmission screening report, the director of the training center or designee
shall provide the written decision on the admission request to the CSB.

VA.R. Doc. No. R19-5200; Filed October 23, 2018, 11:53 a.m.

TITLE 12. HEALTH

STATE BOARD OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES

Fast-Track Regulation

Title of Regulation: 12VAC35-200. Regulations for Emergency
and Respite Care Admission to State Training Centers (amending 12VAC35-200-10, 12VAC35-200-20,
12VAC35-200-30).

Statutory Authority: §§ 37.2-203 and 37.2-807 of the
Code of Virginia.

Basis: Section 37.2-203 of the Code of Virginia
authorizes the State Board of Behavioral Health and Developmental Services to
adopt regulations that may be necessary to carry out the provisions of Title
37.2 of the Code of Virginia and other laws of the Commonwealth administered by
the commissioner and the department.

Purpose: This action is the result of a periodic review.
No comments were received during the review. With only two exceptions, the
amendments are not substantive and merely update language to mirror language in
the Code of Virginia or in 12VAC35-115, Regulations to Assure the Rights of
Individuals Receiving Services from Providers Licensed, Funded, or Operated by
the Department of Behavioral Health and Developmental Services. The two
substantive changes are (i) the addition of the definition of "regional
support team" (RST) and the function of the RST to the discharge planning
process, which is initiated at admission, and (ii) consultation with the
assistant commissioner having responsibility for the training center as a part
of the admission process. These two changes mirror practices that have been in
place since 2012.

Chapter 8 (§ 37.2-800 et seq.) of Title 37.2 of the Code of
Virginia allows for emergency or respite admissions to state training centers
operated by the Department of Behavioral Health and Developmental Services
(DBHDS). For an emergency situation that can be supported through a training
center admission after all community resources have been exhausted, or family
members or caregivers who seek relief through respite, this regulation is
essential to protect the health, safety, and welfare of citizens because it
makes clear the procedures for individual emergency and respite admissions to
state training centers operated by the Department of Behavioral Health and
Developmental Services.

Rationale for Using Fast-Track Rulemaking Process: This
action is the result of a periodic review. No comments were received during the
review. The amendments merely update language to mirror current language in
state law, regulation, or practices that have been in place since 2012.

Substance: The amendments (i) update definitions of
authorized representative, community services board, individual, and training
center; (ii) add definitions of admission, department, intellectual disability,
and regional support team; (iii) add "in consultation with" to two
sections to include RSTs in the process described in 12VAC35-200-20 regarding
the application for admission and to include the assistant commissioner having
responsibility for the training center in 12VAC35-200-30 regarding the criteria
for admission; and (iv) delete the definition for "mental
retardation" and the term wherever it appears throughout the regulation.

Issues: This action is the result of a periodic review,
which includes a public comment period. The proposed amendments will provide
clarity for interested stakeholders and the developmental services system,
including DBHDS, community services boards, individuals receiving services, and
their families, by providing updated language to mirror language in the Code of
Virginia and 12VAC35-115, and current practice. There are no disadvantages to
the public or the Commonwealth.

Small Business Impact Review Report of Findings: This
fast-track regulatory action serves as the report of the findings of the
regulatory review pursuant to § 2.2-4007.1 of the Code of Virginia.

Department of Planning and Budget's Economic Impact
Analysis:

Summary of the Proposed Amendments to Regulation. As the result
of a periodic review,1 the State Board of Behavioral Health and
Developmental Services (Board) proposes to: 1) add a definition for "regional
support team" (RST);2 2) specify that community services boards
(CSB) must consult with the RST: prior to preparing an application for respite
care at a state training center,3 in determining whether respite
care for the individual in question is available in the community, and in
determining whether an application for emergency admission is appropriate due
to a lack of services in the community; 3) specify that the director of the
training center consult with the assistant commissioner responsible for the
training center: in determining eligibility for respite care services or
emergency admission, and whether the training center is able to provide
emergency services; and 4) update language to mirror language in § 37.2-100 of
the Code of Virginia4 or in 12 VAC 35-115, Regulations to Assure the
Rights of Individuals Receiving Services from Providers Licensed, Funded, or
Operated by the Department Of Behavioral Health and Developmental Services.5

Result of Analysis. The benefits likely exceed the costs for
the proposed regulation.

Estimated Economic Impact:

Background. The Regulations for Emergency and Respite Care
Admission to State Training Centers are designed to: 1) inform individuals,
authorized representatives, Department of Behavioral Health and Developmental
Services (DBHDS) employees, CSB staff, and pertinent stakeholders of the
process and procedures related to admitting individuals with an intellectual
disability to state training centers for the purpose of providing emergency and
respite supports, 2) educate responsible persons on the approved criteria for
emergency and respite admissions to training centers, and 3) inform individuals
and authorized representatives of the appeal process if they should disagree
with the admission decision.

In 2012, the federal government and Virginia entered into a
settlement agreement6 concerning how the Commonwealth provides
services to its intellectually and developmentally disabled population. As a
result of that settlement agreement, RSTs were created, and CSBs were required
to consult with the RST for the functions that are proposed to be added in this
action. Additionally, the director of training centers have been required to
consult with the assistant commissioner as described above.

Analysis. The proposal to update language to mirror the Code of
Virginia and 12VAC35-115 provides improved clarity and does not affect
requirements in practice. The existence of and requirement for consultation
with RSTs, and the requirement for consultation with the assistant commissioner,
have been legally required through the settlement agreement since 2012. Thus,
the only impact of the proposed language amendments would be to better inform
the public of current legal requirements and procedures. Consequently, the
benefits of the proposed amendments exceed the costs.

Projected Impact on Employment. The proposed amendments do not
affect employment.

Effects on the Use and Value of Private Property. The proposed
amendments do not affect the user and value of private property.

Real Estate Development Costs. The proposed amendments do not
affect real estate development costs.

Small Businesses:

Definition. Pursuant to § 2.2-4007.04 of the Code of Virginia,
small business is defined as "a business entity, including its affiliates,
that (i) is independently owned and operated and (ii) employs fewer than 500
full-time employees or has gross annual sales of less than $6 million."

Costs and Other Effects. The proposed amendments do not affect
costs for small businesses.

Alternative Method that Minimizes Adverse Impact. The proposed
amendments do not adversely affect small businesses.

Adverse Impacts:

Businesses. The proposed amendments do not adversely affect
businesses.

Localities. The proposed amendments do not adversely affect
localities.

Other Entities. The proposed amendments do not adversely affect
other entities.

2Regional support team is defined as "a group of
professionals with expertise in serving individuals with developmental
disabilities in the community appointed by the commissioner or his designee who
provide recommendations to support placement in the most integrated setting
appropriate to an individual's needs and consistent with the individual's
informed choice."

3Respite care is defined as "care provided to an
individual with mental retardation (intellectual disability) on a short-term
basis because of the emergency absence of or need to provide routine or
periodic relief of the primary caregiver for the individual. Services are
specifically designed to provide temporary, substitute care for that which is
normally provided by the primary caregiver."

Agency's Response to Economic Impact Analysis: The
Department of Behavioral Health and Developmental Services concurs with the
economic impact analysis.

Summary:

The amendments (i) specify that community services boards
must consult with the regional support team regarding respite care services and
emergency admissions, (ii) specify that the director of the training center
consult with the assistant commissioner responsible for the training center in
determining eligibility for respite care services or emergency admission, and
(iii) update language.

12VAC35-200-10. Definitions.

The following words and terms when used in this chapter shall
have the following meanings unless the context clearly indicates otherwise:

"Admission" means acceptance of an individual in
a training center.

"Authorized representative" or "AR"
means a person permitted by law or regulations to authorize the disclosure of
information or to consent to treatment and services, including
medical treatment, or for the participation in human research on
behalf of an individual who lacks the mental capacity to make these decisions.

"Commissioner" means the Commissioner of the
Department of Behavioral Health and Developmental Services.

"Community services board" or "CSB" means
a public body established pursuant to § 37.2-501 of the Code of Virginia that
provides mental health, developmental, and substance abuse services to
individuals within each city and county that established it. For the
purpose of these regulationsthis chapter, CSB also includes a
behavioral health authority established pursuant to § 37.2-602 of the Code of
Virginia.

"Department" means the Department of Behavioral
Health and Developmental Services.

"Discharge plan" means a written plan prepared by
the CSB providing case management, in consultation with the training center
pursuant to §§ 37.2-505 and 37.2-837 of the Code of Virginia. This plan is
prepared when the individual is admitted to the training center and documents
the services to be provided upon discharge.

"Emergency admission" means the temporary
acceptance of an individual with mental retardation (intellectual
disability)an intellectual disability into a training center when
immediate care is necessary and no other community alternatives are available.

"Guardian" means:

1. For minors -- an adult who is either appointed by the court
as a legal guardian of a minor or exercises the rights and responsibilities of
legal custody by delegation from a biological or adoptive parent upon
provisional adoption or otherwise by operation of law.

2. For adults -- a person appointed by the court who is
responsible for the personal affairs of an incapacitated adult under the order
of appointment. The responsibilities may include making decisions regarding the
individual's support, care, health, safety, habilitation, education and
therapeutic treatment. Refer to definition of "incapacitated person"
at § 37.2-100064.2-2000 of the Code of Virginia.

"Individual" means a person with an intellectual
disability for whom respite or emergency services are sought. This
term includes the terms "consumer," "patient,"
"resident," and "client."

"Intellectual disability" means a disability
originating before the age of 18 years, characterized concurrently by (i)
significant subaverage intellectual functioning as demonstrated by performance
on a standardized measure of intellectual functioning administered in
conformity with accepted professional practice that is at least two standard
deviations below the mean and (ii) significant limitations in adaptive behavior
as expressed in conceptual, social, and practical adaptive skills.

"Less restrictive setting" means the service
location that is no more intrusive or restrictive of freedom than reasonably
necessary to achieve a substantial therapeutic benefit and protection from harm
(to self and others) based on an individual's needs.

"Mental retardation (intellectual disability)"
means a disability, originating before the age of 18 years, characterized
concurrently by (i) significantly subaverage intellectual functioning as
demonstrated by performance on a standardized measure of intellectual
functioning, administered in conformity with accepted professional practice,
that is at least two standard deviations below the mean; and (ii) significant
limitations in adaptive behavior as expressed in conceptual, social, and
practical adaptive skills.

"Regional support team" or "RST" means
a group of professionals with expertise in serving individuals with
developmental disabilities in the community appointed by the commissioner or
the commissioner's designee who provide recommendations to support placement in
the most integrated setting appropriate to an individual's needs and consistent
with the individual's informed choice.

"Respite care" means care provided to an individual
with mental retardation (intellectual disability)an intellectual
disability on a short-term basis because of the emergency absence of or
need to provide routine or periodic relief of the primary caregiver for the
individual. Services are specifically designed to provide temporary, substitute
care for that which is normally provided by the primary caregiver.

"Training center" means a facility operated by the Department
of Behavioral Health and Developmental Services for the treatment,department
that provides training, or habilitation of, or other
individually focused supports to persons with mental retardation
(intellectual disability)intellectual disabilities.

12VAC35-200-20. Respite care admission.

A. Applications for respite care in training centers shall be
processed through the CSB providing case management. A parent, guardian, or
authorized representative seeking respite care for an individual with mental
retardation (intellectual disability)an intellectual disability
shall apply first to the CSB that serves the area where the individual, or if a
minor, histhe minor's parent or guardian is currently residing. The
CSB shall consult with the RST prior to preparing an application for respite
care. If the CSB, in consultation with the RST, determines that
respite care for the individual is not available in the community, itthe
CSB shall forward an application to thea training center
serving individuals with mental retardation (intellectual disability) from
that geographic section of the state in which the individual or his parent or
guardian is currently residingintellectual disabilities.

The application shall include:

1. An application for services;

2. A medical history indicating the presence of any current
medical problems as well as the presence of any known communicable disease. In
all cases, the application shall include any currently prescribed medications
as well as any known medication allergies;

3. A social history and current statushousing or
living arrangements;

4. A psychological evaluation that reflects the individual's
current functioning;

5. A current individualized education plan for school agedschool-aged individuals unless the training center director or designee
determines that sufficient information as to the individual's abilities and
needs is included in other reports received;

6. A vocational assessment for adults unless the training
center director or designee determines that sufficient information as to the
individual's abilities and needs is included in other reports received;

7. A statement from the CSB that respite care is not available
in the community for the individual;

8. A statement from the CSB that the appropriate arrangements
are being made to return the individual to the CSB within the time frametimeframe required under this regulationchapter; and

9. A statement from the individual, a family member, or
authorized representative specifically requesting services in the training
center.

B. Determination of eligibility for respite care services
shall be based upon the following criteria:

1. The individual has a diagnosis of mental retardation
(intellectual disability)intellectual disability and meets the
training center's regular admission criteria;

2. The individual's needs are such that, in the event of a
need for temporary care, respite care would not be available in a less
restrictive setting; and

3. The training center has appropriate resources to meet the
needs of the individual.

By the end of the next working day following receipt of a
complete application package, the training center director, or the
director's designee, in consultation with the assistant commissioner
responsible for the training center or the director's designee, shall
provide written notice of histhe director's decision to the CSB.
This notice shall state the reasons for the decision.

If it is determined that the individual is not eligible for
respite care, the person seeking respite care may ask for reconsideration of
the decision by submitting a written request for such reconsideration to the
commissioner. Upon receipt of such request, the commissioner or designee shall
notify the training center director, and the training center director
shall forward the application packet and related information to the
commissioner or designee within 48 hours. The commissioner or designee shall
provide an opportunity for the person seeking respite care to submit for
consideration any additional information or reasons as to why the admission
should be approved. The commissioner shall render a written decision on the
request for reconsideration within 10 days of the receipt of such request and
notify all involved parties. The commissioner's decision shall be binding.

C. Respite care shall be provided in training centers under
the following conditions:

1. The length of the respite care stay at the training center
shall not exceed the limits established in § 37.2-807 of the Code of
Virginia;

2. Space and adequate staff coverage are available on a
residential living area with an appropriate peer group for the individual and
suitable resources to meet his needs; and

3. The training center has resources to meet the individual's
health care needs during the scheduled respite stay as determined by a physical
examination performed by the training center's health service personnel at the
time of the respite admission.

If for any reason a person admitted for respite care is not
discharged at the agreed upon time, the CSB shall develop an updated discharge
plan as provided in §§ 37.2-505 and 37.2-837 of the Code of Virginia.

Respite shall not be used as a mechanism to circumvent the
voluntary admissions procedures as provided in § 37.2-806 of the Code of
Virginia.

12VAC35-200-30. Emergency admission.

A. In the event of a change in an individual's circumstances
necessitating immediate, short-term care for an individual with mental
retardation (intellectual disability)an intellectual disability, a
parent, guardian, or authorized representative may request emergency admission
by calling the CSB serving the area where the individual, or in the case of a
minor, histhe minor's parent or guardian resides. Under these
circumstances if the CSB, in consultation with the RST, determines that
services for the individual are not available in the community, itthe
CSB may request an emergency admission to thea training
center serving that geographic areaindividuals with intellectual
disabilities.

The CSB shall make every effort to obtain the same case
information required for respite admissions, as described in 12VAC35-200-20 A,
before the training center assumes responsibility for the care of the
individual in need of emergency services. However, if the information is not
available, this requirement may temporarily be waived if, and only if,
arrangements have been made for receipt of the required information within 48
hours of the emergency admission.

B. Acceptance for emergency admission shall be based upon the
following criteria:

1. A change in the individual's circumstances has occurred
requiring immediate alternate arrangements to protect the individual's health
and safety;

3. All other alternate care resources in the community have
been explored and found to be unavailable;

4. Space is available on a residential living area with
appropriate resources to meet the individual's needs;

5. The training center's health services personnel have
determined that the individual's health care needs can be met by the training
center's resources; and

6. The length of the emergency stay at the training center
shall not exceed the limits established in § 37.2-807 of the Code of
Virginia.

C. Within 24 hours of receiving a request for emergency
admission, the training center director, or the director's
designee, in consultation with the assistant commissioner responsible for
the training center or his designee, shall inform the CSB whether the
individual is eligible for emergency admission and whether the training center
is able to provide emergency services.

If the training center is able to provide emergency services,
arrangements shall be made to effect the admission as soon as possible.

If the training center is unable to provide emergency
services to an eligible individual, the training center director or designee
shall provide written notice of this determination to the CSB and may offer in
consultation with department staff to try to obtain emergency services from
another appropriate facility.

If for any reason a person admitted to a training center for
emergency services is not discharged at the agreed upon time, the CSB shall
develop a discharge plan as provided in §§ 37.2-505 and 37.2-837 of the
Code of Virginia.

VA.R. Doc. No. R19-5201; Filed October 23, 2018, 11:57 a.m.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

COMMON INTEREST COMMUNITY BOARD

Final Regulation

REGISTRAR'S NOTICE: The
Common Interest Community Board is claiming an exemption from Article 2 of the
Administrative Process Act in accordance with § 2.2-4006 A 4 a of the Code
of Virginia, which excludes regulations that are necessary to conform to
changes in Virginia statutory law where no agency discretion is involved. The
Common Interest Community Board will receive, consider, and respond to
petitions by any interested person at any time with respect to reconsideration
or revision.

Pursuant to Chapters 33 and 133 of the 2018 Acts of
Assembly, the amendments change the requirements for (i) escrow of deposits for
time-share purchases, (ii) the bond or letter of credit required to be filed
with the Common Interest Community Board to insure escrow deposits, and (iii)
the registration for time-shares and time-share resellers.

18VAC48-45-20. Definitions.

A. Section 55-362 of the Code of Virginia provides
definitions of the following terms and phrases as used in this chapter:

"Affiliate"

"Offering" or "offer"

"Alternative purchase"

"Person"

"Association"

"Product"

"Board"

"Project"

"Board of directors"

"Public offering statement"

"Common elements"

"Purchaser"

"Contact information"

"Resale purchase contract"

"Contract" or "purchase contract"

"Resale time-share"

"Conversion time-share project"

"Resale service"

"Default"

"Resale transfer contract"

"Developer"

"Reseller"

"Developer control period"

"Reverter deed"

"Development right"

"Situs"

"Dispose" or "disposition"

"Time-share"

"Exchange company"

"Time-share estate"

"Exchange program"

"Time-share expense"

"Guest"

"Time-share instrument"

"Incidental benefit"

"Time-share owner" or "owner"

"Lead dealer"

"Time-share
program" or "program"

"Managing agent"

"Time-share project"

"Managing entity"

"Time-share unit" or "unit"

"Material change"

"Time-share use"

"Transfer"

B. The following words and terms when used in this chapter
shall have the following meanings unless the context clearly indicates
otherwise:

"Alternative disclosure statement" means a
disclosure statement for an out-of-state time-share program or time-share
project that is properly registered in the situs.

"Annual report" means a completed, board-prescribed
form and required documentation submitted in compliance with § 55-394.1 of
the Code of Virginia.

"Application" means a completed, board-prescribed
form submitted with the appropriate fee and other required documentation in
compliance with the Virginia Real Estate Time-Share Act and this chapter.

"Blanket bond" means a blanket surety bond
issued in accordance with the requirements of § 55-375 of the Code of Virginia
obtained and maintained by a developer in lieu of escrowing deposits accepted
by a developer in connection with the purchase or reservation of a product.

"Blanket letter of credit" means a blanket
irrevocable letter of credit issued in accordance with the requirements of § 55-375
of the Code of Virginia obtained and maintained by a developer in lieu of
escrowing deposits accepted by a developer in connection with the purchase or
reservation of a product.

"Department" means the Department of Professional
and Occupational Regulation.

"Firm" means a sole proprietorship, association,
partnership, corporation, limited liability company, limited liability
partnership, or any other form of business organization recognized under the
laws of the Commonwealth of Virginia.

"Full and accurate disclosure" means the degree of
disclosure necessary to ensure reasonably complete and materially accurate
representation of the time-share in order to protect the interests of
purchasers.

"Individual bond" means an individual surety
bond issued in accordance with the requirements of § 55-375 of the Code of
Virginia obtained and maintained by a developer in lieu of escrowing a deposit
accepted by a developer in connection with the purchase or reservation of a
product.

"Individual letter of credit" means an
individual irrevocable letter of credit issued in accordance with the
requirements of § 55-375 of the Code of Virginia obtained and maintained
by a developer in lieu of escrowing a deposit accepted by a developer in
connection with the purchase or reservation of a product.

"Registration file" means the application for
registration, supporting materials, annual reports, and amendments that
constitute all information submitted and reviewed pertaining to a particular
time-share program, time-share project, alternative purchase, exchange company,
or time-share reseller registration. A document that has not been accepted for
filing by the board is not part of the registration file.

18VAC48-45-130. Minimum application requirements for
registration of a time-share project.

A. The documents and information contained in §§ 55-367,
55-368, 55-369, 55-371, 55-374, and 55-391.1 of the Code of Virginia, as
applicable, shall be included in the application for registration of a
time-share project.

B. The application for registration of a time-share project
shall include the fee specified in 18VAC48-45-70.

C. The following documents shall be included in the
application for registration of a time-share project as exhibits. All exhibits
shall be labeled as indicated and submitted in a format acceptable to the
board.

1. Exhibit A: A copy of the certificate of incorporation or
certificate of authority to transact business in Virginia issued by the
Virginia State Corporation Commission, or any other entity formation documents,
together with any trade or fictitious name certificate.

2. Exhibit B: A certificate of recordation or other acceptable
documents from the city or county where the time-share is located.

3. Exhibit C: A copy of the title opinion, the title policy,
or a statement of the condition of the title to the time-share project
including encumbrances as of a specified date within 30 days of the date of
application by a title company or licensed attorney who is not a salaried
employee, officer, or director of the developer or owner, in accordance with
subdivision A 5 of § 55-391.1 of the Code of Virginia. If the developer is not
the record owner of the land, a copy of any contract the developer has executed
to purchase the land, any option the developer holds for the purchase of the
land, or any lease under which the developer holds the land.

4. Exhibit D: Proof that the applicant or developer owns or
has the right to acquire an estate in the land constituting or to constitute
the time-share project, which is of at least as great a degree and duration as
the estate to be conveyed in the time-share.

5. Exhibit E: A statement of the zoning, subdivision, or land
use obligations or proffers and other governmental regulations affecting the
use of the time-share, including the site plans and building permits and their
status, any existing tax, and existing or proposed special taxes or assessments
that affect the time-share.

6. Exhibit F: A copy of the time-share instrument, including
all applicable amendments and exhibits, that will be delivered to a purchaser
to evidence the purchaser's interest in the time-share and of the contracts and
other agreements that a purchaser will be required to agree to or sign.

7. Exhibit G: A narrative description of the promotional plan
for the disposition of the time-shares.

8. Exhibit H: A copy of the proposed public offering statement
that complies with § 55-374 of the Code of Virginia and this chapter. Pursuant
to subsection G of § 55-374, a similar disclosure statement required by other
situs laws governing time-sharing may be submitted for a time-share located
outside of the Commonwealth.

9. Exhibit I: A copy of the buyer's acknowledgment. Pursuant
to § 55-376.5 of the Code of Virginia, the purchaser shall be given this
document prior to signing a purchase contract, and the document shall contain
the information required by subsection B of § 55-376.5.

10. Exhibit J: Copies of bonds or letters of credit issued
by a financial institution, if any, required by subsection C of § 55-375The signed original of (i) any bond or letter of credit obtained pursuant to
§ 55-375 of the Code of Virginia in lieu of escrowing deposits and (ii)
any bond or letter of credit required by subsection B of § 55-386 of the
Code of Virginia, as applicable.

11. Exhibit K: A copy of any management agreements and other
contracts or agreements affecting the overall use, maintenance, management, or
access of all or any part of the time-share project.

12. Exhibit L: A list with the names of every officer,
manager, owner, or principal, as applicable to the type of firm under which the
developer is organized to do business, of the developer or persons occupying a
similar status within or performing similar functions for the developer. The
list must include each individual's residential address or other address valid
for receipt of service, principal occupation for the past five years, and
title.

13. Exhibit M: A statement whether any of the individuals or
entities named in Exhibit L are or have been involved as defendants in any
indictment, conviction, judgment, decree, or order of any court or
administrative agency against the developer or managing entity for violation of
a federal, state, local, or foreign country law or regulation in connection
with activities relating to time-share sales, land sales, land investments,
security sales, construction or sale of homes or improvements, or any similar
or related activity.

14. Exhibit N: A statement whether, during the preceding five
years, any of the individuals or entities named in Exhibit L have been
adjudicated bankrupt or have undergone any proceeding for the relief of
debtors.

15. Exhibit O: If the developer has reserved the right to add
to or delete from the time-share program any incidental benefit or alternative
purchase, a description of the incidental benefit or alternative purchase shall
be provided pursuant to subdivision A 13 of § 55-391.1 of the Code of Virginia.

16. Exhibit P: Conversion time-share projects must attach a
copy of the notice required by subsection D of § 55-374 of the Code of Virginia
and a certified statement that such notice shall be mailed or delivered to each
of the tenants in the building or buildings for which the registration is
sought at the time of the registration of the conversion project.

18VAC48-45-220. Narrative sections; terms of offering.

A. The public offering statement shall contain a section
captioned "Terms of the Offering." The section shall discuss the
expenses to be borne by a purchaser in acquiring a time-share and present
information regarding the settlement of purchase contracts as provided in
subsections B through H of this section.

B. The section shall indicate any initial or special fees due
from the purchaser at settlement including a description of the purpose of such
fees.

C. The section shall set forth a general description of any
financing offered by or available through the developer to purchasers.

D. The section shall describe (i) services that the developer
provides or expenses it pays and that it expects may become at any subsequent
time a time-share expense of the owners and (ii) the projected time-share
expense liability attributable to each of those services or expenses for each
time-share.

E. The section shall discuss all penalties or forfeitures to
be incurred by a purchaser upon default in performance of a purchase contract.

F. The section shall discuss the process for cancellation of
a purchase contract by a purchaser in accordance with § 55-376 of the Code of
Virginia. The section shall include a statement that the purchaser has a
nonwaivable right of cancellation and refer such purchaser to that portion of
the contract in which the right of cancellation may be found.

G. The section shall describe the terms of the deposit escrow
requirements, including a statement, if applicable, that the developer has
filed a surety bond or letter of credit with the board in lieu of escrowing
deposits, in accordance with § 55-375 of the Code of Virginia. The section
shall also state that deposits may be removed from escrow at the
terminationand no longer protected by a surety bond or letter of credit
after the expiration of the cancellation period.

H. The section shall set forth all restrictions in the
purchase contract that limit the time-share owner's right to bring legal action
against the developer or the association. The section shall set forth the
paragraph or section and page number of the purchase contract where such
provision is located. Nothing in this statement shall be deemed to authorize
such limits where those limits are otherwise prohibited by law.

A. Subsequent to the issuance of a registration for a
time-share by the board, the developer of a time-share shall do the following:

1. File an annual report in accordance with § 55-394.1 of the
Code of Virginia and this chapter.

2. Upon the occurrence of a material change, file an amended
public offering statement in accordance with the provisions of subsection E of
§ 55-374 and subsection C of § 55-394.1 of the Code of Virginia and this
chapter. These amendments shall be filed with the board within 20 business days
after the occurrence of the material change.

3. Upon the occurrence of any material change in the
information contained in the registration file, the developer shall immediately
report such material changes to the board in accordance with the provisions of
subsection B of § 55-391.1 of the Code of Virginia.

4. Notify the board of a change in theany bond
or letter of credit, as applicable, filed with the board in accordance with
§ 55-375 of the Code of Virginia or required by subsection C of § 55-375
and subsection B of § 55-386 of the Code of Virginia.

5. File a completed application for registration of an
unregistered phase or phases upon the expansion of the time-share, along with
the appropriate fee specified in 18VAC48-45-70.

6. Notify the board of transition of control from the
developer to the time-share estate owners' association (time-share estate
projects only).

7. Submit appropriate documentation to the board once the
registration is eligible for termination.

8. Submit to the board any other document or information,
which may include information or documents that have been amended or may not
have existed previously, that affects the accuracy, completeness, or
representation of any information or document filed with the application for
registration.

9. Submit to the board any document or information to make the
registration file accurate and complete.

B. Notwithstanding the requirements of subsection A of this
section, the board at any time may require a developer to provide information
or documents, or amendments thereof, in order to assure full and accurate
disclosure to prospective purchasers and to ensure compliance with the Virginia
Real Estate Time-Share Act and this chapter.

18VAC48-45-350. Nonmaterial changes to the public offering
statement.

Changes to the public offering statement that are not
material are not required to be filed with the board, shall not be deemed an
amendment of the public offering statement for the purposes of this chapter,
and shall not give rise to a renewed right of rescission in any purchase.
Nonmaterial changes to the public offering statement include, but may not be
limited to, the following:

1. Correction of spelling, grammar, omission, or other similar
errors not affecting the substance of the public offering statement;

2. Changes in presentation or format;

3. Substitution of an executed, filed, or recorded copy of a
document for the otherwise substantially identical unexecuted, unfiled, or
unrecorded copy of the document that was previously submitted;

4. Inclusion of updated information such as identification or
description of the current officers and directors of the developer;

5. Disclosure of completion of improvements for improvements
that were previously proposed or not complete;

6. Changes in real estate tax assessment or rate or
modifications related to those changes;

7. Changes in utility charges or rates or modifications
related to those changes;

8. Addition or deletion of incidental benefits or alternative
purchases provided the developer reserved in the time-share instrument the
right to add or delete incidental benefits or alternative purchases;

9. Adoption of a new budget that does not result in a
significant change in fees or assessments or significantly impact the rights or
obligations of the prospective purchasers;

10. Modifications related to changes in insurance company or
financial institution, policy, or amount for bonds or letters of credit filed
with the board in accordance with § 55-375 of the Code of Virginia or
required pursuant to §§ 55-375 and§ 55-386 of the Code of
Virginia;

11. Changes in personnel of the managing agent; and

12. Any change that is the result of orderly development of
the time-share in accordance with the time-share instruments as described in
the public offering statement.

A. A developer shall file an annual report for a time-share
project registration on a form provided by the board to update the material
contained in the registration file by June 30 of each year the registration is
effective and shall be accompanied by the fee specified in 18VAC48-45-70. Prior
to filing the annual report required by § 55-394.1 of the Code of Virginia, the
developer shall review the public offering statement then being delivered to
purchasers. If such public offering statement is current, the developer shall
so certify in the annual report. If such public offering statement is not
current, the developer shall amend the public offering statement and the annual
report shall, in that event, include a filing in accordance with
18VAC48-45-360.

B. The annual report shall contain, but may not be limited
to, the following:

1. Current contact information for the developer;

2. Information concerning the current status of the time-share
project;

3. Information concerning the current status of the time-share
program, including (i) the type of time-shares being offered and sold; (ii) the
total number of time-share interests available in the program; (iii) the total
number of time-share interests sold; and (iv) information regarding any
incomplete units and common elements;

4. If the project is a time-share estate project and the
developer control period has not yet expired, a copy of the annual report that
was prepared and distributed by the developer to the time-share owners required
by § 55-370.1 of the Code of Virginia must accompany the annual report;

5. Date of the public offering statement currently being
delivered to purchasers; and

6. Current evidence from the surety or financial institution
of bonds or letters of credit, or submittal of replacement bonds or letters
of credit,filed with the board in accordance with § 55-375 of the Code
of Virginia or required pursuant to subsection C of § 55-375 and
subsection B of § 55-386 of the Code of Virginia, or submittal of
replacement bonds or letters of credit. Such verification shall provide the
following:

a. Principal of bond or letter of credit;

b. Beneficiary of bond or letter of credit;

c. Name of the surety or financial institution that issued the
bond or letter of credit;

d. Bond or letter of credit number as assigned by the issuer;

e. The dollar amount; and

f. The expiration date or, if self-renewing, the date by which
the bond or letter of credit shall be renewed; and

g. For any blanket bond or blanket letter of credit, a
statement of the total amount of deposits held by the developer as of May 31 of
that calendar year.

18VAC48-45-430. Return of bond or letter of credit upon
termination of time-share project registrationfiled in lieu of
escrowing deposits.

A. An individual bond or individual letter of credit on
file with the board in accordance with § 55-375 of the Code of Virginia may be
returned to the developer upon written request. Such request shall include a
statement from the developer that indicates (i) the purchaser's cancellation
period has expired, (ii) the purchaser's default under a purchase contract for
the time-share estate entitling the developer to retain the deposit, or (iii)
the purchaser's deposit was refunded.

B. Upon issuance of an order of termination of the
time-share project registration pursuant to 18VAC48-45-450, thea
blanket bond or blanket letter of credit on file with the board for
the purpose of protecting all deposits escrowed pursuant to subsection C ofin accordance with § 55-375 of the Code of Virginia will be
returned to the developer.

18VAC48-45-440. Maintenance of bond or letter of credit.

A. The developer shall report the extension, cancellation,
amendment, expiration, termination, or any other change of any bond or letter
of credit submitted in accordance with subsection C of § 55-375 and
subsection B of § 55-386 of the Code of Virginia within five days of the
change.

B. The board at any time may request verification from the
developer of the status of a bond or letter of credit on file with the board.
Such verification shall comply with the provisions of subdivision B 6 of
18VAC48-45-400.

C. Failure to report a change in the bond or letter of credit
in accordance with this section shall result in further action by the board
pursuant to the Virginia Real Estate Time-Share Act.

18VAC48-45-670. Requirements for registration as a time-share
reseller.

A. Individuals or firms that provide any time-share resale
services shall submit an application on a form prescribed by the board and
shall meet the requirements of this section, including:

1. The information contained in § 55-394.3 of the Code of
Virginia.

2. The application fee specified in 18VAC48-45-70.

3. All contact information applicable to the time-share
reseller and the lead dealer.

B. Any individual or firm offering resale services as defined
in § 55-362 of the Code of Virginia shall be registered with the board. All
names under which the time-share reseller conducts business shall be disclosed
on the application. The name under which the firm conducts business and holds
itself out to the public (i.e., the trade or fictitious name) shall also be
disclosed on the application. Firms shall be organized as business entities
under the laws of the Commonwealth of Virginia or otherwise authorized to
transact business in Virginia. Firms shall register any trade or fictitious
names with the State Corporation Commission or the clerk of court in the
jurisdiction where the business is to be conducted in accordance with §§
59.1-69 through 59.1-76 of the Code of Virginia before submitting an
application to the board.

C. The applicant for a time-share reseller registration shall
disclose the firm's mailing address and the firm's physical address. A post
office box is only acceptable as a mailing address when a physical address is
also provided.

D. In accordance with § 54.1-204 of the Code of Virginia,
each applicant for a time-share reseller registration shall disclose the
following information about the firm, the lead dealer, and any of the
principals of the firm, if applicable:

1. All felony convictions.

2. All misdemeanor convictions in any jurisdiction that
occurred within three years before the date of application.

3. Any plea of nolo contendere or finding of guilt regardless
of adjudication or deferred adjudication shall be considered a conviction for
the purposes of this section. The record of conviction certified or
authenticated in such form as to be admissible in evidence under the laws of
the jurisdiction where convicted shall be admissible as prima facie evidence of
such guilt.

E. The applicant shall obtain and maintain a bond or
letter of credit pursuant to § 55-375 of the Code of Virginia, for the purpose
of protecting deposits and refundable moneys received by a time-share reseller
from clients in the Commonwealth of Virginia in connection with the purchase,
acquisition, or sale of a time-share.

F.E. The applicant for time-share reseller
registration shall be in compliance with the standards of conduct set forth in
Part X (18VAC48-45-720 et seq.) of this chapter at the time of application,
while the application is under review by the board, and at all times when the
registration is in effect.

G.F. The applicant for time-share reseller
registration, the lead dealer, and all principals of the firm shall be in good
standing in Virginia and in every jurisdiction and with every board or
administrative body where licensed, certified, or registered, and the board, in
its discretion, may deny registration to any applicant who has been subject to,
or whose lead dealer or principals have been subject to, any form of adverse
disciplinary action, including but not limited to, reprimand,
revocation, suspension or denial, imposition of a monetary penalty, required to
complete remedial education, or any other corrective action, in any
jurisdiction or by any board or administrative body or surrendered a license,
certificate, or registration in connection with any disciplinary action in any
jurisdiction prior to obtaining registration in Virginia.

H.G. The applicant for time-share reseller
registration shall provide all relevant information about the firm, the lead
dealer, and of the principals of the firm for the seven years prior to
application on outstanding judgments, past-due tax assessments, defaults on
bonds, or pending or past bankruptcies and specifically shall provide all
relevant financial information related to providing resale services as defined
in § 55-362 of the Code of Virginia.

I.H. The application for time-share reseller
registration shall include the exhibits required pursuant to 18VAC48-45-680.

18VAC48-45-680. Exhibits required for registration as a
time-share reseller.

A. The following documents shall be included as exhibits to
the application for registration. All exhibits shall be labeled as indicated
and submitted in a format acceptable to the board.

1. Exhibit A: A copy of the certificate of incorporation or
certificate of authority to transact business in Virginia issued by the
Virginia State Corporation Commission, or any other entity formation documents,
together with any trade or fictitious name certificate.

2. Exhibit B: A copy of the resale purchase contract.

3. Exhibit C: A copy of the resale transfer contract.

4. Exhibit D: A copy of disclosures required by § 55-380.1 of
the Code of Virginia.

5. Exhibit E: A narrative description of the marketing or
advertising plan.

6. Exhibit F: A bond or letter of credit in accordance with
subsection E of 18VAC48-45-670.

B. The board has the sole discretion to require additional
information or amendment of existing information as the board finds necessary
to ensure full and accurate disclosure and compliance with the provisions of §
55-380.1 of the Code of Virginia and to ensure compliance with the provisions
of § 55-394.3 of the Code of Virginia.

18VAC48-45-690. Renewal and reinstatement of a time-share
reseller registration.

A. A time-share reseller registration issued under this
chapter shall expire one year from the last day of the month in which it was
issued. The fee specified in 18VAC48-45-70 shall be required for renewal.

B. Prior to the expiration date shown on the registration, a
registration shall be renewed upon payment of the fees specified in 18VAC48-45-70
and submittal of proof of a current bond or letter of credit required in
accordance with subsection E of 18VAC48-45-670.

C. The board will send a renewal notice to the regulant at
the last known address of record. Failure to receive this notice shall not
relieve the regulant of the obligation to renew. If the regulant fails to
receive the renewal notice, a copy of the registration may be submitted with
the required fees as an application for renewal. By submitting a renewal fee,
the regulant is certifying continued compliance with this chapter, as
applicable, and certifying that all documents required for registration
pursuant to 18VAC48-45-680 on file with the board reflect the most current
version used by the reseller.

D. If the requirements for renewal of a registration as
specified in this chapter are not completed more than 30 days and within six
months after the registration expiration date, the reinstatement fee specified
in 18VAC48-50-70 shall be required.

E. A registration may be reinstated for up to six months
following the expiration date. After six months, the registration may not be
reinstated under any circumstances, and the firm or individual must meet
all current entry requirements and apply as a new applicant.

F. The board may deny renewal or reinstatement of
registration for the same reasons as it may refuse initial registration or
discipline a registrant.

G. The date the renewal application and fee are received in
the office of the board shall determine whether a registration shall be renewed
without reinstatement, or shall be subject to reinstatement application
procedures.

H. A registration that is reinstated shall be regarded as
having been continuously registered without interruption. Therefore, the
registration holder shall remain under the disciplinary authority of the board
during the entire period and shall be accountable for its activities during the
period. Nothing in this chapter shall divest the board of its authority to
discipline a registration holder for a violation of the law or regulation
during the period of time for which the regulant was registered.

I. Applicants for renewal shall continue to meet all of the
qualifications for registration set forth in 18VAC48-45-680.

18VAC48-45-770. Prohibited acts.

The following acts are prohibited and any violation may
result in action by the board, including but not limited to issuance of
a temporary cease and desist order in accordance with subdivision D 2 of
§ 55-396 of the Code of Virginia:

1. Violating, inducing another to violate, or cooperating with
others in violating any of the provisions of any regulation of the board or the
Virginia Real Estate Time-Share Act or engaging in any act enumerated in §§ 54.1-102
and 54.1-111 of the Code of Virginia.

2. Obtaining or attempting to obtain a registration by false
or fraudulent representation, or maintaining, renewing, or reinstating a
registration by false or fraudulent representation.

3. Failing to alter or amend the public offering statement or
disclosure document as required in accordance with the provisions of this
chapter.

4. Providing information to purchasers in a manner that
willfully and intentionally fails to promote full and accurate disclosure.

5. Making any misrepresentation or making a false promise that
might influence, persuade, or induce.

6. Failing to provide information or documents, or amendments
thereof, in accordance with this chapter.

7. Failing to comply with the post-registration requirements
of this chapter.

8. Filing false or misleading information in the course of
terminating a registration in accordance with 18VAC48-45-450,
18VAC48-45-460, 18VAC48-50-56018VAC48-45-560, or 18VAC48-50-63018VAC48-45-630.

9. Failing to comply with the advertising standards contained
in Part III (18VAC48-45-80 et seq.) of this chapter.

10. Failing to notify the board of the cancellation,
amendment, expiration, termination, or any other change that affects the
validity of a bond or letter of creditrequired pursuant to subsection E
of 18VAC48-45-670.

11.10. Allowing a registration issued by the
board to be used by another.

12.11. A regulant having been convicted, found
guilty, or disciplined in any jurisdiction of any offense or violation
described in subdivisions C 13 and C 14 of 18VAC48-45-130, subdivisions 4 and 5
of 18VAC48-45-210, and subsections D, GF, and HG
of 18VAC48-45-670.

13.12. Failing to inform the board in writing
within 30 days that the regulant was convicted, found guilty, or disciplined in
any jurisdiction of any offense or violation described in subsections D, GF, and HG of 18VAC48-45-670.

14.13. Failing to report a change as required
by 18VAC48-45-470.

15.14. Failing to satisfy any judgments or
restitution orders entered by a court or arbiter of competent jurisdiction.

16.15. Misrepresenting or misusing the intended
purpose of a power of attorney or similar document to the detriment of any
grantor of such power of attorney.

17.16. Engaging in dishonest ofor
fraudulent conduct in providing resale services, including but not limited
to the following:

a. The intentional and unjustified failure to comply with the
terms of the resale purchase contract or resale transfer contract.

c. Failing to comply with the recordkeeping requirements of §
55-394.4 of the Code of Virginia.

d. Failing to disclose information in writing concerning the
marketing, sale, or transfer of resale time-shares required by this chapter
prior to accepting any consideration or with the expectation of receiving
consideration from any time-share owner, seller, or buyer.

e. Making false or misleading statements concerning offers to
buy or rent; the value, pricing, timing, or availability of resale time-shares;
or numbers of sellers, renters, or buyers when engaged in time-share resale
activities.

f. Misrepresenting the likelihood of selling a resale
time-share interest.

g. Misrepresenting the method by or source from which the
reseller or lead dealer obtained the contact information of any time-share
owner.

h. Misrepresenting price or value increases or decreases,
assessments, special assessments, maintenance fees, or taxes or guaranteeing
sales or rentals in order to obtain money or property.

i. Making false or misleading statements concerning the
identity of the reseller or any of its affiliates or the time-share resale
entity's or any of its affiliate's experience, performance, guarantees,
services, fees, or commissions, availability of refunds, length of time in
business, or endorsements by or affiliations with developers, management
companies, or any other third party.

j. Misrepresenting whether or not the reseller or its
affiliates, employees, or agents hold, in any state or jurisdiction, a current
real estate sales or broker's license or other government-required license.

k. Misrepresenting how funds will be utilized in any
time-share resale activity conducted by the reseller.

l. Misrepresenting that the reseller or its affiliates,
employees, or agents have specialized education, professional affiliations,
expertise, licenses, certifications, or other specialized knowledge or
qualifications.

m. Making false or misleading statements concerning the
conditions under which a time-share owner, seller, or buyer may exchange or
occupy the resale time-share interest.

n. Representing that any gift, prize, membership, or other benefit
or service will be provided to any time-share owner, seller, or buyer without
providing such gift, prize, membership, or other benefit or service in the
manner represented.

o. Misrepresenting the nature of any resale time-share
interest or the related time-share plan.

p. Misrepresenting the amount of the proceeds, or failing to
pay the proceeds, of any rental or sale of a resale time-share interest as
offered by a potential renter or buyer to the time-share owner who made such
resale time-share interest available for rental or sale through the reseller.

q. Failing to transfer any resale time-share interests as
represented and required by this chapter or to provide written evidence to the
time-share owner of the recording or transfer of such time-share owner's resale
time-share interest as required by this chapter.

r. Failing to pay any annual assessments, special assessments,
personal property or real estate taxes, or other fees relating to an owner's
resale time-share interest as represented or required by this chapter.

NOTICE: Forms used in
administering the regulation have been filed by the agency. The forms are not
being published; however, online users of this issue of the Virginia Register
of Regulations may click on the name of a form with a hyperlink to access it.
The forms are also available from the agency contact or may be viewed at the
Office of the Registrar of Regulations, 900 East Main Street, 11th Floor,
Richmond, Virginia 23219.

Basis: Section 46.2-1052 of the Code of Virginia
authorizes the Superintendent of State Police to promulgate regulations
stipulating size and location of stickers or decals.

Purpose: In 2017, the regulations relating to the
placement of the Virginia motor vehicle inspection sticker were amended to
shift the placement of that sticker from the lower center to the lower
left-hand corner of the windshield when viewed from inside the vehicle. That
amendment impacts the optional placement of the sticker and requires this
regulation to be amended to reflect the new proper positioning for the county,
city, or town sticker. The change is necessary to allow for the lawful
placement of the county sticker so that it does not interfere with the operator's
vision and will not obstruct the proper placement of the inspection sticker.
Improper placement of stickers on the windshield would interfere with the
operator's vision and endanger the public by limiting the operator's ability to
observe pedestrians, hazards, and other traffic.

Rationale for Using Fast-Track Rulemaking Process: The
amendment is intended to ensure that the placement of the county, city, or town
sticker does not interfere with the placement of the Virginia inspection
sticker and to ensure that any placement does not illegally interfere with the
vehicle operator's clear field of vision. The change in placement provides two
options and does not add or remove any requirement for such sticker.

Substance: 19VAC30-40-30 is amended to allow the owner
of the vehicle an option to place a county, city, or town sticker or decal
either next to the Virginia motor vehicle inspection sticker in the lower
driver's side corner of the windshield or behind the rear view mirror. The
current regulation allows a placement that may interfere with proper display of
the inspection sticker.

Issues: The amendment ensures that the placement of the
county, city, or town sticker does not interfere with the placement of the mandatory
Virginia inspection sticker and prohibits placements that would impair the
driver's field of vision. There are no advantages or disadvantages to the
public, Commonwealth, or agency in the placement of the sticker other than the
improper placement may limit the operator's visibility thereby endangering the
public.

Department of Planning and Budget's Economic Impact
Analysis:

Summary of the Proposed Amendments to Regulation. The
Department of State Police (DSP) proposes to amend the text concerning where
owners of vehicles in localities where stickers or decals are used in lieu of
license plates may place the sticker or decal on their vehicle. The proposed
change is in response to a change to the Motor Vehicle Safety Inspection
Regulations (19VAC30-70) that produced a conflict.

Result of Analysis. The benefits likely exceed the costs for
all proposed changes.

Estimated Economic Impact. The current Standards and
Specifications for the Stickers or Decals Used By Cities, Counties and Towns in
Lieu of License Plates (19VAC30-40) states that the sticker or decal shall be
placed at the bottom of the windshield adjacent to the right side of the
official inspection sticker when viewed through the windshield from inside the
vehicle, or may be affixed at the lower left corner of the windshield.

Through an exempt action1 that became effective on
January 26, 2018, DSP amended the Motor Vehicle Safety Inspection Regulations
(19VAC30-70) to shift the required placement of the Virginia motor vehicle
inspection sticker from the lower center to the lower left hand corner of the
windshield, when viewed from inside the vehicle. That amendment affects the
optional placement of the sticker or decal used by counties, cities, and towns
in lieu of license plates.

Thus, DSP proposes to amend Standards and Specifications for
the Stickers or Decals Used By Cities, Counties and Towns in Lieu of License
Plates (19VAC30-40) to reflect a new positioning for the county of city sticker
that does not conflict with the Commonwealth's inspection sticker. That
location is "the blind spot behind the rear view mirror." The
proposed amendment produces a net benefit since it eliminates a conflict with
another regulation, and does not produce a cost.

Businesses and Entities Affected. The proposed amendment
affects owners of vehicles in the counties and cities that require a county or
city sticker or decal.

Projected Impact on Employment. The proposed amendment would
not affect employment.

Effects on the Use and Value of Private Property. The proposed
amendment would not significantly affect the use and value of private property.

Real Estate Development Costs. The proposed amendment would not
affect real estate development costs.

Small Businesses:

Definition. Pursuant to § 2.2-4007.04 of the Code of Virginia,
small business is defined as "a business entity, including its affiliates,
that (i) is independently owned and operated and (ii) employs fewer than 500
full-time employees or has gross annual sales of less than $6 million."

Costs and Other Effects. The proposed amendment would not
affect costs for small businesses.

Alternative Method that Minimizes Adverse Impact. The proposed
amendment would not adversely affect small businesses.

Adverse Impacts:

Businesses. The proposed amendment would not adversely affect
businesses.

Localities. The proposed amendment would not adversely affect
localities.

Other Entities. The proposed amendment would not adversely
affect other entities.

Agency's Response to Economic Impact Analysis: The
agency has reviewed and concurs with the economic impact analysis prepared and
submitted by the Department of Planning and Budget.

Summary:

The amendment specifies the size and location of stickers placed
on the windshields of motor vehicles in the cases where a sticker is required
by a county, city, or town. A required sticker may be placed either behind the
rear view mirror or adjacent to the Virginia motor vehicle inspection sticker
located in driver's side lower corner of the windshield.

19VAC30-40-30. Placement.

The sticker or decal shall be placed at the bottom of the windshield
adjacent to the right side of the official inspection sticker when viewed
through the windshield from inside the vehicle. The side edge adjacent to the
official inspection sticker shall not be more than 1/4 inch from the edge of
the official inspection sticker. At the option of the motor vehicle's owner,
the sticker or decal, provided it measures not more than two and one-half
inches in width and four inches in length, may be affixed at the lower
left corner of the windshield so that the inside or left edge of the sticker or
decal is within one inch of the extreme left edge of the windshield when
looking through the windshield from inside the vehicle. When placed at this
location, the bottom edge of the sticker or decal must be affixed within three
inches of the bottom of the windshieldplaced in the blind spot behind
the rear view mirror.